UNITED STATES PROBATION SYSTEM AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION TO TREATMENT PROVIDER I, (offender), the undersigned, hereby authorize the United States Probation Office for the Eastern District of Missouri to release confidential information in its records, possession, or knowledge, of whatever nature may now exist or come to exist to (vendor). The confidential information to be released may include: offender’s address, offender’s telephone number, offender’s employment information, and the offender’s prior treatment information. The release also authorizes the release of any information which may assist the vendor in providing treatment/counseling. The information which I now authorize for release is to be used in connection with my participation in the afore-mentioned program which has been made a condition of my supervision. I understand the vendor may use the information hereby obtained only in connection with treatment the vendor is providing to me while I am on federal supervision. I understand this authorization is valid until my release from supervision, at which time this authorization to use or disclose this information expires. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law. I understand I have the right to revoke this authorization, in writing, at any time by sending such written notification to United States Probation Office for the Eastern District of Missouri. I understand if I revoke this authorization to release confidential information, I will thereby revoke my authorization to further disclosure of such information. I also understand that revoking this authorization before I satisfy the condition of my supervision that requires me to participate in the program will be reported to the court. My revocation of authorization under such circumstances could be considered a violation of a condition of my post-conviction supervision. (Signature of Probation Officer) (Signature of Offender) (Date Signed) (Date Signed) C:\Documents and Settings\tbauer\Local Settings\Temp\notesC7A056\revised Form 11B.wpd American LegalNet, Inc. www.FormsWorkflow.com