Download CHISAGO COUNTY COURT SERVICES CONSENT FOR THE

CHISAGO COUNTY COURT SERVICES
CHISAGO COUNTY GOVERNMENT CENTER
313 North Main Street, Room 124
Center City, MN 55012
Phone: 651-213-8350 Fax: 651-213-8351
E-Mail: [email protected]
CONSENT FOR THE RELEASE OF INFORMATION
I, __________________________________________, Date of Birth ______/______/___________
(CLIENT PRINTED NAME)
authorize BRUCE HAGSTROM, SARA PRIGGE, JEFF SCHULTZ, MARNIE HUMENIUK ,
JOCELYN WORDEN, or PETER MONSON, Chisago County Court Officers, to disclose to, or
obtain from: (Print name where information is coming from) __________________________________________
any and all information pertaining to the above named client, for the purpose of Monitoring probation
conditions or Court ordered assessments, programs and counseling. The requested information may
include: Chemical Dependency Assessment, Anger/Domestic Assault Assessment, or Psychological
Assessment; Chemical Dependency Treatment, Anger Management Treatment or Psychological
Treatment; any counseling program or pertinent medical information.
I understand that my records are protected under the Minnesota Government Data
Practices Act, Minnesota Statutes, Chapter 13, and cannot be disclosed without my
written consent or unless otherwise provided by law. I understand that this data may, after its
release to the above named entity, be defined as Court Services Data, as defined by
Minnesota Statutes, Section 13.84, Subdivision 1, and/or Corrections and Detention Data, as
defined by Minnesota Statutes 13.85, Subdivision 1, and as a result may be classified as
either public, private, or confidential data as defined by the provisions of Minnesota Statute
13. 02. I also understand that I may revoke this consent at any time, except to the extent that
action has been taken in reliance on it (e.g. probation, parole, supervised release, work
release, etc.) and, that in any event this consent expires automatically as described below.
Federal confidentiality regulations (42 CFR Part 2) prohibit re-disclosure of information
from alcohol and drug abuse patient records.
This release of information expires upon discharge of the subject from Court Supervision.
_________________________________________
Today’s Date
________________________________________
Client Signature