Information Consent Form

Your Name

Your First NameYour Last Name
Your Birth Date

MonthDayYear
Date
SSN
I hereby authorize and request Fifth Street Counseling Center IV, Inc. to release, receive or exchange information with:
Check ALL that apply:

AttorneyBroward-Dade Safety Counsel DUIBSO- Pretrial ServicesBSO- ProbationChildNet - Child AdvocateDCF - Child Protective Services (CPIS)Department of Juvenile Justice (DJJ)DOC- ProbationGuardian Ad LitemHenderson- FEPJudge/Court OrderOut Of State/County Probation OfficerOut Of State/County DUI SchoolOtherMetro Traffic
Release information to the following person(s):
Full Name (ie. Case Manager, Attorney, Probation Officer, etc.)
Agency
Phone
Email
Full Name
Agency
Email
example@example.com
Phone
Full Name
Agency
Email
example@example.com
Phone
I understand that my records are protected under Federal regulations governing Confidentiality of Alcohol and Drug Abuse Initials Patients Records, 42 C.F.R. Part 2, and the health insurance portablility and accountability act of 1996("HIPPA") 45 C.F.R. pts 160 & 164 and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent action has been taken in reliance on it, and that in any event, this consent expires automatically one year from today. I hereby authorize and request Fifth Street Counseling IV, Inc. to release, receive or exchange information with the above named person(s) or agency.
Initials
I hereby release Fifth Street Counseling Center IV, Inc. and the above named persons or institutions from all legal Initials responsibility or liability that may arise from the exchange of this information. I waive my rights to confidentiality for any legal proceedings arising from this release or exchange of information. A copy of this document, for my records is available to me upon request.
Initials
Client/Guardian Signature

Clear
Date

MonthDayYear
Date
Client ID#
Initials
Should be Empty: