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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