King County District Court MHC RELEASE OF INFORMATION I,_______________________________________, DOB_________________ authorize Valley Cities Counseling (VCCC) and the King County District Court Probation Division Assigned to King County District Mental Health Court to disclose and obtain information from the following agencies: -King County Jail Psychiatric Services 500 5th Ave. Seattle, WA 98104 -King County Jail Health Services 500 5th Ave. Seattle, WA 98104 -King County District Court 516 3rd Ave. Seattle, WA 98104 & The Associated Counsel for the Accused - ________________________________________________________________ - ________________________________________________________________ This authorization applies to the following types of information; - Mental Health Diagnosis and Treatment -Medical Diagnosis and Treatment -Jail/Custody data - Alcohol and Drug Abuse Treatment I understand that this information is protected under RCW 70.96A and federal law 42 CFR, Part 2. - Other____________________________________________________________ The above information will be used by the King County District Mental Health Court for the purposes of (a) coordinating treatment services; (b) providing referral information; and (c) monitoring for compliance with a treatment program, including informing the court of diagnosis, treatment issues, participation in treatment, attendance or non-attendance, progress, prognosis and completion of treatment. I understand that my records may be confidential, depending on the information contained in them, under one or more of the following statutes or regulations: Medical Records (including mental health records)- RCW 70.02; Drug or Alcohol Treatment Records- RCW 70.96A.150 an/or Code of Federal Regulations, Title 42, Volume1 Part 2. I understand that medical records and drug and alcohol treatment records generally cannot be disclosed without my written consent. This authorization is valid for the duration of the court’s supervision/monitoring period in Case #________________. I waive my durational limits and any revocation rights that might otherwise apply to this release. __________________________________________ _________________________________ Signature of client date Signature of Witness date May 2011 American LegalNet, Inc. www.FormsWorkFlow.com