Butte — Veterans’ Treatment Court Consent for Release of Confidential Information

Source: https://www.butte.courts.ca.gov/system/files/mil-veterans-treatment-court-consent-release-confidential-info.pdf

Butte County Superior Court—Treatment Courts Veterans’ Treatment Court CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION: CRIMINAL JUSTICE SYSTEM REFERRAL I, _______________________________________, authorize (initial whichever parties apply): (Name of defendant) BCSC—TC __________(Initial) Butte County Probation employees working my case ___________(initial) Butte County Behavioral Health/Department of Veterans Affairs employees working my case __________(initial) ______________________________________________ (Name of the appropriate drug court) District Attorney Michael L. Ramsey and/or his designee (s) working my case _________(initial) Public Defender Desiree Vance _________(Initial) To communicate with and disclose to one another the following information (nature and amount of the information as limited as possible) _______ my diagnosis, urinalysis results, information about my attendance or lack of attendance at treatment sessions, my cooperation with the treatment program, prognosis, and

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The purpose of the disclosure is to inform the person(s) listed above of my attendance and progress in treatment. I understand that my alcohol and /or drug treatment records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. Parts 160 & 164. 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 as follows: ________ There has been a successful completion or a termination from a treatment court. ________ 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 mandate into treatment, or

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(Specify other time when consent can be revoked and/or expired) 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 drug 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 Veterans’ Treatment Court. I have been provided a copy of this form. I acknowledge that I have 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 right and I am signing this Consent voluntarily. Dated:____________ _____________________________________________________________ (Signature of Veterans’ Treatment Court Participant) Witness:__________________________________________ _________________________________________ (Position) PROHIBITION ON REDISCLOSURE OF CONFIDENTIAL INFORMATION This notice accompanies a disclosure of information concerning a client in alcohol/drug treatment, made to you with the consent of such client. This information has been disclosed to you from records protected by federal confidentiality rules (42 C.F.R. Part 2) The federal rules 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 other wise permitted by 42 C.F.R. Part 2). A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of this information to criminally investigate or prosecute any alcohol or drug abuse patient.