RHODE ISLAND ADULT DRUG COURT SUPERIOR COURT 250 BENEFIT STREET PROVIDENCE, RI 02903 RELEASE OF CONFIDENTIAL INFORMATION Information Regarding: Name: ___________________ Case No.: _________________ Address:___________________ ___________________ ___________________ DOB: ___________________ I, ___________________________, authorize the Drug Court Case Coordination Providers and their Direct Service Provider agents, my current and prior schools, my employer, my treatment provider(s), and any other person or agency in possession of employment, medical, psychiatric, treatment, educational, mental health, or other documents and records which are deemed necessary for Drug Court purposes, to release such information to the Judge/Magistrate or his representative(s) from the: Rhode Island Adult Drug Court Superior Court 250 Benefit Street Providence, RI 02903 Tel: (401) ____________ Fax: (401) ___________ Social Security No.:___-__-____ BCI No. ___________________ The requested information is necessary for the Court to make an initial determination as to my eligibility for substance abuse treatment services and is also required on an ongoing basis to track my progress with the Drug Courts program conditions. The free flow of information is vital to the success of this Drug Court Program, and I voluntarily consent to the release and re-release of information which is considered necessary for Drug Court purposes. I understand that any information gathered by the aforementioned individuals and agencies, including the Drug Court Case Coordination Provider and the Direct Service Provider(s), will be re-released to the Drug Court for Drug Court purposes. I further understand that the information gathered by the Rhode Island Superior Adult Drug Court may be re-released to all necessary individuals and agencies. (Alcohol, drug and mental health records include all aspects of diagnosis, treatment and prognosis. Educational records include all attendance, special service, behavioral and academic progress reports). I understand that my records are protected under the Federal Regulations governing confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR, Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the Regulations. 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 one (1) year after the date signed, unless an earlier date is specified by a formal and effective termination of my involvement with the Drug Court Program. Termination from the Drug Court Program will occur upon the discontinuation of all court supervision as a result of either the successful completion of the Drug Court Program requirements or upon discharge for violating the terms of the Drug Court Program. The Adult Drug Court Program will inform the disclosing agency of the revocation or expiration of consent. I understand that this is a limited disclosure for the purposes as stipulated above and any disclosure is bound by Title 42 C.F.R. Part 2, which governs the confidentiality of substance abuse patient records. The Federal Rules prohibit further disclosure of this information unless such a disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by Title 42 CFR, Part 2. It is a crime to violate this Federal confidentiality requirement, which the participant may report to the appropriate authorities. The Federal Rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. However, Federal Law does not protect information relating to crimes committed on the premises of the program, crimes against program personnel, or the abuse or neglect of a child. _____________________________________ _________________________________ Signature of Participant Date Signature of Witness Date American LegalNet, Inc. www.FormsWorkFlow.com