SOP_NUMBER: 107.04-att-1
TITLE: Release of Information Form
REFERENCE_CODE: VB01-0006
DIVISION: Georgia Department of Corrections
TOPIC_AREA: 107 Policy-Counseling/Risk Reduction
EFFECTIVE_DATE: 2022-03-02
WORD_COUNT: 228
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/122509
URL: https://gps.press/sop-data/107.04-att-1/

SUMMARY:
This form authorizes the Georgia Department of Corrections to release assessment results and case plan information from an offender's records to a designated family member or friend for treatment assistance purposes. The form allows offenders to specify which information may be released, maintain confidentiality of shared records, and withdraw consent at any time. The authorization remains in effect throughout the offender's incarceration unless an earlier expiration date is specified.

KEY_TOPICS: release of information, authorization form, offender records, case plan, assessment results, confidentiality, consent, family notification, inmate records release, treatment information, privacy authorization

ATTACHMENTS:
  1. Release of Information Form
     URL: https://gps.press/sop-data/107.04-att-1/

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FULL TEXT:
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SOP 107.04
Attachment 1

03/02/22


**GEORGIA DEPARTMENT OF CORRECTIONS**

**Release of Information Form**

___________________________________ ____________________________
Name of Offender GDC Number


**AUTHORIZATION FOR RELEASE OF INFORMATION**

I hereby request and authorize: ____________________________________________________

(Name of GDC site releasing Information)
____________________________________________________

(Address)


To release to: __________________________________________________________________

(Name of Family or Friend Receiving the Information)


_________________________________________________________________

(Address)
The following information from my records:

**ASSESSMENT RESULTS AND CASE PLAN** _____________________________________

For the purpose of: **ASSISTING IN MY TREATMENT** _______________________________

All information I hereby authorize to be released from the GDC will be held strictly confidential
and cannot be released by the GDC to any other person without my written consent unless
required by state or federal law. I understand that this authorization will remain in effect for the
period of my incarceration unless I specify an earlier expiration date here: _________________.

(Date)

I understand that unless otherwise limited by state or federal regulation, and except to the extent
that action has been taken which was based on my consent, I may withdraw this consent at any
time.
________________________________ ______________________________________
(Signature of Offender) (Date)
________________________________ ______________________________________
(Signature of Witness & Title) (Date)
________________________________ ______________________________________
(Signature of Parent or Authorized Representative if under age of consent) (Date)

______________________________________________________________________________

**USE THIS SPACE ONLY IF OFFENDER WITHDRAWS CONSENT**


(This form applies to offenders incarcerated in all GDC facilities, private prisons, or county correctional
facilities.)


Retention Schedule: Upon completion, the original copy with all signatures shall be placed in the offender’s
(detainee and inmate) institutional case file.