CONSENT FOR THE RELEASE OF ... - Pullman, Washington
CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION
TO THE DEPARTMENT OF LICENSING
I _____________________________, Date of Birth: _______________________
FULL NAME
Driver’s License Number: _______________________, authorize PALOUSE RIVER COUNSELING Name of Program Making Disclosure
to disclose to the Washington State Department of Licensing information regarding my alcohol and/or drug assessment, information school involvement, participation in treatment, progress in treatment, and program compliance and non-compliance. The purpose of this disclosure is to monitor my program involvement as a result of an alcohol and/or drug related license restriction, and may be used in arriving at a decision regarding my driving privilege in the State of Washington. I further consent for this information to be re-disclosed to the Washington State Department of Social and Health Services, Division of Alcohol and Substance Abuse, for purposes of chemical dependency program monitoring.
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, except as indicated above and otherwise provided for in the regulations, cannot be re-disclosed without my written consent. 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 90 days following the date of termination of services from the program.
I acknowledge that I am aware this form will be submitted electronically and approve of this method of submission.
SIGNATURE OF PATIENT/CLIENT DATE
WITNESS DATE
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