**Notice of Rights of Confidentiality**

**For Drug Court Participants**

**CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE PATIENT RECORDS**

*Notification Form from 42C.F.R.§2.22(d)*

The confidentiality of alcohol and drug abuse patient records maintained
by this program is protected by federal law and regulations. Generally,
the program may not say to a person outside the program that a patient
attends the program, or disclose any information identifying a patient
as an alcohol or drug abuser, unless:

(1) The patient consents in writing;

(2) The disclosure is allowed by a court order; or

(3) The disclosure is made to medical personnel in a medical emergency
    or to qualified personnel for research, audit, or program
    evaluation.

Violation of the federal law and regulations by a program is a crime.
Suspected violations may be reported to appropriate authorities in
accordance with federal regulations.

Federal law and regulations do not protect any information about a crime
committed by a patient either at the program or against any person who
works for the program or about any threat to commit such a crime.

Federal laws and regulations do not protect any information about
suspected child abuse or neglect from being reported under state law to
appropriate state or local authorities.

As a participant in the Drug Court Program we are providing you with
this Notice of Rights of Confidentiality for Drug Court Participants to
advise you of your rights of confidentiality and the disclosure of
confidential information. You may elect to waive your rights to
confidentiality as defined within this notice by signing the *Consent
For Disclosure of Confidential Substance Abuse Treatment Information:
Drug Court Referral* which provides the necessary consent from you to
allow the disclosure of confidential information as provided in section
(1) "the patient consents in writing," of this Notice.

(See 42 U.S.C. § 290dd-3 and 42 U.S.C. § 290ee-3 for federal laws and 42
C.F.R. Part 2 for federal regulations.)

CONSENT FOR DISCLOSURE OF CONFIDENTIAL SUBSTANCE ABUSE TREATMENT

INFORMATION: DRUG COURT REFERRAL

I,
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_,
being the Defendant in Case Number
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, and having agreed to
enroll and participate in the Montgomery County Adult Drug Court
Program, hereby consent to allow on-going communications about my
compliance status among the following Parties or agencies involved in
the Drug Court Program: The Honorable Nelson Rupp, Associate Judge of
the Circuit Court, (or his Judicial Designee), the employees engaged in
the Drug Court operations of the Montgomery County Circuit Court, the
Montgomery County Department of Health and Human Services (DHHS), The
State's Attorney's Office (SAO), the Office of the Public Defender (OPD)
or my private counsel, the Department's of Parole and Probation and
Correction and Rehabilitation, and/or other referring or treating
agencies involved in the direct delivery of services through the
Montgomery County Adult Drug Court Program.

I understand that the purpose of, and the need for this disclosure, is
to: inform the court and the other above-named parties or agencies of my
eligibility and/or acceptability for substance abuse treatment services;
to report on and adequately monitor my treatment, attendance, prognosis,
and compliance with the terms and conditions of my probation; to discuss
and assess my status as a participant in the Drug Court Program; and, to
assess and comment on my progress in accordance with the Drug Court's
reporting and monitoring criteria.

I agree to permit disclosure of this confidential information only as
necessary for, and pertinent to, hearings, and/or reports concerning the
status of my participation and compliance with the conditions of my
probation as defined by the Drug Court. I understand that information
about my medical status, mental health and/or drug treatment status, my
arrest history, my levels of compliance or non-compliance with the
conditions of my Drug Court participation (including the results of
urinalysis or other drug screening tools,) and other material
information will be discussed and shared among members of the Drug Court
team. I further understand that summary information about my compliance
or non-compliance will be discussed in open court, specifically, whether
I have attended all meetings, treatment sessions, the results of
urinalysis or alcoscan testing as required, and the disclosure of my
compliance or noncompliance with the terms and conditions of my
probation as defined by the Court.

I understand that treatment information normally is confidential under
federal law. I understand that any disclosure made is bound by Part 2 of
Title 42 of the Code of Federal Regulations, which governs the
confidentiality of substance abuse patient (or client) records and that
it is a crime to violate this confidentiality requirement unless I
voluntarily consent to permit its disclosure. Recipients of this
information may re-disclose it only in connection with their official
duties.

I understand that this consent will remain in effect and cannot be
revoked by me until there has been a formal and effective termination of
my involvement with the drug court for the case named above such as the
discontinuation of all court-ordered supervision or probation upon my
successful completion of the drug court requirements, or upon sentencing
for violating the terms of my drug court involvement.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date \_\_\_\_\_\_\_\_\_\_\_\_

SIGNATURE OF PROGRAM PARTICIPANT

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date \_\_\_\_\_\_\_\_\_\_\_\_\_

Signature of Witness