SOP 508.15-att-3: Authorization for Release of Information (Mental Health Services)

SOP 508.15
Attachment 3

8/15/22

GEORGIA DEPARTMENT OF CORRECTIONS Facility: ______________________________________

MENTAL HEALTH SERVICES Name: _______________________________________

AUTHORIZATION FOR RELEASE ID #:_________________________________________

OF INFORMATION Race: _____________ Sex: ____________

__________________________________________________________________________________________________

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby request and authorize: ________________________________________________ (Name of Person/Agency)

___________________________________________________________________________________________________________
(Address)
to release the following type(s) of information from my records (and any specific portion thereof):

[ ] Dates of Hospitalization [ ] History [ ] Treatment Record

[ ] Academic Record [ ] Discharge Summary [ ] Physical Exam

[ ] Psychological Report [ ] Psychiatric Report [ ] Other

Release information to: ______________________________________________________ (Name of Person/Agency)

___________________________________________________________________________________________________________
(Address)

for the purpose of __________________________________________________________________________________
All information I hereby authorize to be obtained will be held strictly confidential and cannot be released by the recipient
without my written consent. I understand that this authorization will remain in effect for ninety (90) days unless I specify
an earlier expiration date here: ____________________.

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.

SIGN BELOW FOR GENERAL CONSENT TO RELEASE INFORMATION
PLEASE NOTE: Two witnesses are required if patient signs by a mark (X). One witness is required for all other
signatures.
______________________________________ _________ _____________________________ __________
Signature of Witness (Title/Relationship) Date Signature of Offender/Client/Patient Date

_________________________________________ __________ ________________________________ __________
Signature of Witness (Title/Relationship) Date Signature of Parent/Auth. Representative Date
(where applicable)
IMPORTANT: Please sign below for release of the following specific information.

I, _______________________________________, consent to the release of confidential alcohol and drug information.

I,________________________________________, consent to the release of confidential information concerning the
testing for HIV (Human Immunodeficiency Virus) and/or treatment for AIDS (Acquired Immune Deficiency Syndrome)
and related conditions.
__________________________________________________________________________________________________
USE THIS SPACE ONLY IF OFFENDER/CLIENT/PATIENT WITHDRAWS CONSENT

_____________________________________________ _____________________________________________
(Date this consent is revoked by Offender/client/patient) Signature of Offender/client/patient

Form no. M31-01-03 Page 1 of 1

Retention Schedule: Upon completion, the original form shall be given to the person/agency from whom records are being requested.
A copy shall be placed in the offender’s mental health file (section 5). At the end of the offender’s need for mental health services
and/or sentence, the mental health file shall be placed within the offender’s health record and retained for 10 years.