Problem Solving Court Participant Consent for Release/Disclosure of Confidential Information IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS PROBLEM SOLVING COURT PARTICIPANT CONSENT FOR RELEASE/DISCLOSURE OF CONFIDENTIAL INFORMATION (03/22/16) CCCR N108 I, ___________________________________________________________ Case No.:____________________________________, authorize: (Name of Defendant) The Presiding Judge _______________________________________ and team members of the ______________________________Program (Name of Court) _________________________________________________________ and representatives of the Cook County Adult Probation Department _____________________________________________________________ and representatives of the Cook County State's Attorney's Office _____________________________________________________________ and representatives of the Cook County Public Defender's Office ___________________________________________________________ and representatives of Treatment Alternatives for Safe Communities ___________________________________________________________________________ and representatives of Presence Health System ___________________________________________________ and representatives of any Veterans Health Administration (VHA) hospital or treatment facility or other service provider I am referred to during my participation in the above named program ______________________________________________________ and representatives of the Cook County Sheriff, Cermak Hospital, or any treatment agency providing contract services for the Cook County Sheriff's Department ___________________________________________________________and representatives of the Chief Judge's Office and any other person permitted by the presiding judge to attend team staffing(s) for training and educational purposes. To communicate with and disclose to one another information concerning the following: _______Any evaluation, diagnosis, prognosis, hospitalization, treatment, urinalysis result (including disclosure of test results in open court) or other information concerning my attendance, progress and compliance with treatment, or otherwise related to my health or treatment. The purpose of the disclosure is to inform the court and other named person(s) listed above of my eligibility for treatment and my compliance and progress in treatment pursuant to the conditions of my court ordered participation in treatment. I understand that my health and alcohol and/or drug treatment records are protected under the federal regulations governing Confidentialty of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 CFR Parts. 160 & 164, and that my mental health records are protected under the Illinois Mental Health and Developmental Disabilities Confidentiality Act (MHDDCA), 740 ILCS 110/1. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically when there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment, or _______________________ . (Specify other time) I understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment, or health care operations, if permitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes. I recognize that my review hearings are held in an open and public courtroom and it is possible that an observer could connect my identity with the fact that I am in treatment as a condition of participation in a Cook County Problem Solving Court. I specifically consent to this potential disclosure to third persons. I understand that if I refuse to consent to disclosure or attempt to revoke my consent prior to the expiration of this consent, that such action is grounds for immediate termination from the Cook County Problem Solving Court in which I am enrolled. I acknowledge that I have 1) been provided a copy of this consent form, and 2) been advised of my rights, have received a copy of the advisement, and have had the benefit of legal counsel or have voluntarily waived the right to an attorney. I am not under the influence of drugs or alcohol. I fully understand my rights and I am signing this Consent voluntarily. Dated: ____________________________________________ Witness: __________________________________________________ ________________________________________________________ (Signature of Problem Solving Court Participant) _________________________________________________ (Position) PROHIBITION ON REDISCLOSURE OF CONFIDENTIAL INFORMATION This notice accompanies a disclosure of information concerning a client in alcohol/drug or mental health treatment, made to you with the consent of such client. This information has been disclosed to you from records protected by federal (42 CFR Part 2) and Illinois (740 ILCS 110/1) confidentiality rules/law. Those federal and state rules/law prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2 or 740 ILCS 110/1. A general authorization for the release of medical and other information is NOT sufficient for this purpose. The federal and state rules also restrict any use of this information to criminally investigate or prosecute any alcohol or drug abuse or mental health patient. DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Page 1 of 1