AIP Authorization Release of Information

AIP Authorization Release of Information

Clinical Program
Name*

First NameLast Name
I authorize SARC staff to share information regarding my treatment to the following (check all that apply):

Harford County Parole and ProbationCircuit Court of Harford CountyOther County Parole and ProbationOther County Circuit/District CourtVictim
If other, please specify:
It has been explained and I understand that any information released to a third party can not be guaranteed by SARC staff to remain restricted, as other agencies may not be bound by the same confidentiality requirements.

This release will expire in 8 months, or at the completion of the AIP program. The release of information to Parole and Probation will expire at the time my parole or probation ends.
Client Signature and Date

Clear
Should be Empty: