SOP_NUMBER: 508.15-att-3
TITLE: Authorization for Release of Information (Mental Health Services)
DIVISION: Mental Health Services
TOPIC_AREA: Mental Health Evaluations/Screenings/Treatment
EFFECTIVE_DATE: 2022-08-15
WORD_COUNT: 359
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/350776
URL: https://gps.press/sop-data/508.15-att-3/

SUMMARY:
This form authorizes the release of an inmate's mental health information from GDC records to a specified person or agency. The authorization covers various types of mental health records including hospitalization dates, treatment records, psychological reports, and psychiatric reports. The form requires witness signatures and includes specific consent provisions for alcohol/drug information and HIV/AIDS-related information, with a 90-day validity period unless earlier revoked.

KEY_TOPICS: Authorization for release, mental health records, inmate consent, confidential information, psychological reports, psychiatric records, treatment records, HIV/AIDS information, substance abuse information, records release, patient authorization, form M31-01-03

ATTACHMENTS:
  1. Mental Health Evaluation for Services (Form M31-01-01)
     URL: https://gps.press/sop-data/508.15-att-1/
  2. Mental Status Evaluation (Attachment 2)
     URL: https://gps.press/sop-data/508.15-att-2/
  3. Authorization for Release of Information (Mental Health Services)
     URL: https://gps.press/sop-data/508.15-att-3/
  4. Parole Evaluation Log (Form M31-01-04)
     URL: https://gps.press/sop-data/508.15-att-4/
  5. Requested Records Log
     URL: https://gps.press/sop-data/508.15-att-5/

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FULL TEXT:
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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.