• Date Format: MM slash DD slash YYYY
  • This information is needed for the following purpose(s) pursuant to Minnesota Statute 1973, Chapter 572, Section 16: To aid client with: CASE MANAGEMENT / TREATMENT PLANNING / COLLATERAL INFORMATION

  • This release of information consent remains in effect until CLIENT REVOKES IT IN WRITING or ONE(1) YEAR AFTER COMPLETION OR TERMINATION OF TREATMENT.

    I understand that I may revoke this release at any time, except to the extent that it has already been acted upon. I understand and acknowledge by my signature that this Release of Information Consent' remains in effect as specified unless specifically revoked by me by written notice to Sober Living Connections. I understand that if I am participating in the program as a formal condition of my release from confinement or of a probation/parole order, this consent may not be revoked until there is a formal and effective termination of the conditioned confinement, probation or parole.
  • Date Format: MM slash DD slash YYYY

    This information has been disclosed to you from records protected by Federal Confidentiality rules (42 CFR Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.