CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION I(Required) Name authorize(Required) to disclose to(Required) the following information:(Required) The purpose of the disclosure authorized in this is to:(Required)I understand that all Offender Education Programs shall abide by and obtain any consent to disclosure required by applicable Federal and State laws regarding confidentiality of patient/client records including, as applicable and without limitation, 42 United States Code S290dd-2; 42 Code of Federal Regulations, Part 2, and Health and Safety Code, Chapter 611. I understand my records cannot be disclosed without my written consent unless otherwise provided for by the regulations. I also understand that I may revoke this consent in writing at any time except to the extent that action has been taken in response to it, and that in any event, this consent expires automatically as follows.specification of the date, event, or condition upon which this consent expires(Required) Month Day Year Signature of Participant(Required)Signature of Parent, Guardian or Authorized Representative, where required(Required)Date Signed(Required) Month Day Year BY CLICKING SUBMIT YOU AGREE TO SERVICES. NEXT YOU WILL BE REDIRECTED TO A REGISTRATION FORM email(Required) CAPTCHA Please Click Here After submitting the consent form
