Addiction Awareness OSCA 11-036 response - REDACTED.pdf

ADDICTION AWARENESS, LLC
CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION
to BUCHANAN COUNTY DRUG COURT
I, ____________________________________understand that services are being
provided by ADDICTION AWARENESS, LLC through a contractual agreement with
the Missouri Department of Corrections, Buchanan County Drug Court. As part of this
contract it is necessary that we share information with the representatives of the Missouri
Department of Corrections and Buchanan County Drug Court. I hereby authorize the
ADDICTION AWARENESS LLC to communicate with, disclose and obtain from the
Missouri Department of Corrections/Buchanan County Drug Court, the following
information:
Assessment results, treatment plan and updates, attendance, urinalysis results,
progress in treatment, involvement in program activities, discharge needs,
aftercare plan, and information needed for medical or psychological referral and
their results, and ___________________________________________________
The purpose of and need for the disclosure is to inform the Missouri Department of
Corrections/Buchanan County Drug Court about my treatment requirements and progress
in treatment.
I understand that this consent will remain in effect and cannot be revoked by me until:
_____
_____
There has been a formal and effective termination or revocation of my
release from the Buchanan County Drug Court Program under which I
was referred into treatment, or
_________________________________________________________
(other time when consent can be revoked and/or expires)
I also understand that any disclosure made is bound by Part 2 of Title 42 of the Code of
Federal Regulations governing confidentiality of Alcohol/Drug Abuse patient records and
that recipients of this information may redisclose it only in connection with their official
duties. I hereby release the Addiction Awareness LLC., from any liability which may arise as a result of
the use of the information released to it, or from it, under this consent.
__________________________________________________ __________________
Client Signature Chart # Date
__________________________________________________ __________________
Staff Representative Title Date