IDOC ROI example

IDAHO
DEPARTMENT OF IDAHO DEPARTMENIT OF CORRECTION
CORRECHON `
We envision a safer -Idaho with fewerpeople in its correctional system
BRAD LITTLE Bree Derrick
Governor
Director
REQUEST AND CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION
1. Nanze, address and information of person authorizing releaseofrecords.
Name: l i o 1 `f\ W� Phone:�-�V "2D8 720E.2DOC #
Other names: —� /11� V 40 le—' Date of Birth: 01 [ ( Social Security No:
Mailing Address: 1 `.A_ �vk.. ,Sr, � Cp ` i � S-�g -
2. Statement of Request and Authorization �`" J
I hereby request and authorize communication between the Idaho Department of Correction (IDOC), Division of Probation and
Parole, and any entity contacted by IDOC, including:
The extent of information that may be disclosed, includes the following records and documentation (initial all that apply):
J D Evaluation/Assessments
LegaUCriminal/juvenile records
Psychosexual Evaluation
Counseling records
Jb Medications
Treatment records
) D Mental Health records
SC`s Employment
Education
Q Child support
Social histories
Military
J n Social Security Administration
i) Treatment Court records
Other
—�� Medical records:
from Z3D to CVyyva�k
,S 1 Drug and alcohol treatment
Enrollment
in of rmation, including:
JfJ
Diagnosis/prognosis and/or regarding
Cooperation level
Facility presence
Attendance
Treatment/discharge
The information release is for the purpose(s) of (initial all that apply):
-3 �) Court -ordered presentence investigation —Probation and/or Parole purposes
I understand that the above records are protected under federal regulations including the Health Insurance Portability and Accountability of 199 (HIPAA), 45 C.F.R.
Parts 160 & 164, and/or Confidentiality of Alcohol and Drug Abuse PatientRecords, 42 C.F.R. Part 2, and cannot be disclosed without my written consent unless
otherwise provided for in these regulations. Recipients of this information may re -disclose the information only in connection with their official duties. I understand that
this authorization is subject to revocation by me if provided in writing, except to the extent that disclosure has alreadyoccurred in reliance upon this authorization, and
subject to the conditions explained below. I understand this information may be re-released in accordance with Idaho Criminal Rule 32 for other legal purposes. I
understand that my health care cannot be conditioned on the authorization unless the purpose is solely to obtain and disclose information for a third party, such as an
employer.
SPECIAL TERMS REGARDING REVOCABILITY OF CRUMINAL JUSTICE PROGRAM RELEASES:
Although HIPAA requires that consents be revocable and does not have an exception when a patient is mandated into treatment through the criminal justice system
(CJS), 42 C.F.R. Part 2 sets forth some special rules when a patient's participation in a treatment program is an official condition of probation or parole, sentence,
dismissal of charges, release from imprisonment, or other disposition of any criminal proceeding. While a consent form (or court order) is still required before any
disclosure can be made about a CIS referral, the rules concerning duration and revocability of the consent are different. Under special rules of 42 C.F.R. Part 2, consent
can be made irrevocable until a certain specified date or condition occurs, and the duration of the consent can be linked to the final disposition of the criminal
proceeding. 42 C.F.R. §2.35. This allows programs to provide information even after the client leaves treatment. If the client does not comply with treatment, the
program can report the problem to the judge or prosecuting attorney to testify in a probation revocation hearing because there has been no final disposition of the
criminal matter. A CIS consent allows programs to use the expiration condition provided in 42 C.F.R. Part 2 "when there is a substantial change in the patient's
criminal justice status."A substantial change in status occurs whenever the patient moves from one phase of the CIS to the next. For example, if a client were on parole
or probation, there would be a change in the CIS status when the parole or probation ends, either by successful completion or revocation. Thus the program could
:provide periodic reports to the parole or probation officer monitoring the client, and could even testify at a parole or probation revocation hearing, since no change in
criminal status would occur until after the hearing.
3. Expiration and Release of Liability
I release and forever hold harmless the State of Idaho, IDOC, and their agents and employees from and against all claims, damages, or liability
kesulting from any action pursuant to this request.
Signature 90erson Requesting Release of Records Date
Name of Witness (or Parent/Guardian where required) Signature of Witness Date