Pennsylvania Code › Title 37 - LAW › Part III - Agencies and Offices › Subpart B - Department of Corrections › Chapter 97 - STATE INTERMEDIATE PUNISHMENT DRUG OFFENDER TREATMENT PROGRAM › Section 97.117 - Consent to disclosure of information

Current through Register Vol. 54, No. 28, July 13, 2024
The consent to disclosure of information must be in the
					 following form:
CONSENT
I, the undersigned, hereby give my consent for the
					 Commonwealth of Pennsylvania Department of Corrections, its officers,
					 employees, volunteers, contractors and agents to release and disclose to any
					 court, attorney for the Commonwealth, the Pennsylvania Commission on Sentencing
					 and to my attorney information pertaining to my evaluation for and
					 participation in a drug offender treatment program. This consent to release and
					 disclosure includes medical and dental information, mental health treatment
					 information, drug and alcohol treatment information, criminal history records
					 information and any other information contained in records maintained by the
					 Department of Corrections, its officers, employees, volunteers, contractors and
					 agents. This consent to release and disclosure extends to records pertaining to
					 any period during which I am or was committed to the custody of the Department
					 of Corrections and shall not expire.
Disclosure of medical/dental information may pertain to all
					 aspects of my treatment and hospitalization, including psychological and
					 psychiatric information and drug and/or alcohol information.
Disclosure of mental health records pertains to treatment,
					 hospitalization, and/or outpatient care provided to me for the period listed
					 above. I understand that my record may contain information regarding all
					 aspects of my mental health treatment and hospitalization, including
					 psychological and psychiatric information, drug and/or alcohol
					 information.
In authorizing this disclosure, I expressly waive any and
					 all rights I may have to the confidential maintenance of these records,
					 including any such rights that exist under local, state, and federal statutory
					 and/or constitutional law, rule or order, including those contained in the
					 Pennsylvania Mental Health Procedures Act of 1976 and the Pennsylvania Drug and
					 Alcohol Abuse Control Act of 1972.
I understand that I have no obligation to authorize
					 disclosure of any information from my record and that I may revoke this
					 consent, except to the extent that action has already been taken, at any time
					 by notifying in writing the Medical Records Technician, Health Care
					 Administrator, or Facility Manager. I also understand that revocation of this
					 consent will result in my being expelled from the drug offender treatment
					 program and that I will be resentenced by the court.
I understand that these records are the property of the
					 Department of Corrections and that my authorization for their release does not
					 require the Department of Corrections to release these records.
Furthermore, I will indemnify and hold harmless the
					 Pennsylvania Department of Corrections, and its officers, employees,
					 volunteers, contractors and agents, for any losses, costs, damages, or expenses
					 incurred because of releasing information in accordance with this
					 authorization.
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Signature Date
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Witness Signature Date