Consent For Disclosure Of Confidential Information For Substance Abuse Treatment {L-1207}

SUPERIOR COURT OF CALIFORNIA, COUNTY OF ORANGE JUSTICE CENTER: For Court Use Only Central - 700 Civic Center Dr. West, Santa Ana, CA 92701 Harbor-Newport Beach - 4601 Jamboree Rd., Newport Beach, CA 92660-2595 Lamoreaux - 341 The City Drive, Orange, CA 92868 North - 1275 N. Berkeley Ave., Fullerton, CA 92835 th West - 8141 13 Street, Westminster, CA 92683 PEOPLE OF THE STATE OF CALIFORNIA VS. DEFENDANT: CONSENT FOR DISCLOSURE OF CONFIDENTIAL INFORMATION FOR SUBSTANCE ABUSE TREATMENT UNDER PENAL CODE SECTION 1210 CASE NUMBER: I, , understand that statements and personal information will not be disclosed by the provider, except that the drug treatment provider may disclose to a law enforcement agency information concerning any crime committed by a patient on their premises or against program personnel or an actual threat to commit such a crime, as well as any reports or information regarding suspected child abuse and/or neglect to the extent required under federal or state law. I consent and authorize my PC1210 drug treatment provider (to be named after assessment by the Orange County Health Care Agency) and the Orange County Health Care Agency, to disclose to the Orange County Probation Department, the Orange County Superior Court, the Orange County District Attorney, and counsel for the defendant the following information: The date of my assessment by the Health Care Agency, including the treatment level indicated and the treatment level assigned. The name, address and telephone number of the drug treatment provider to whom I am assigned, as well as the name of any assigned counselors or therapists. Verification of enrollment (or non-enrollment) in the treatment program. Verification of my attendance and participation in any and all treatment or counseling programs. Results of any drug testing by the provider as well as the dates of such tests. The elements, components, rules and requirements of the treatment plan for the level of treatment to which I have been assigned. Progress in treatment (including pertinent information). This waiver of confidentiality shall apply to all treatment providers who are assigned to provide any treatment or counseling, either inpatient or out-patient during the entire time I am under a grant of probation on the above case. I understand that the purpose of this waiver of confidentiality is to provide information concerning my progress on my PC1210 probation case and in the PC1210 drug treatment program. My drug treatment provider shall provide this information to the Orange County Probation Department. This information shall be used for the purpose of evaluating my progress on probation in my PC1210 case and in the PC1210 treatment program. I understand that this consent is subject to revocation at any time except to the extent that the program which is to make the disclosure has already taken action in reliance on it. If this consent is revoked, I understand that I will be discharged from PC1210 drug treatment. If not revoked, this consent will terminate when there has been a court proceeding which ends treatment under PC1210. I understand that any disclosure made is bound by Title 42, Part 2 of the Code of Federal Regulations, which governs the confidentiality of substance abuse patient records and that recipients of this information may re-disclose the information to someone only in connection with their official duties. Dated: Print Name Name and signature of Parent/Guardian (where defendant is a minor): Signature Print Name Signature Signature of interpreter (if necessary) CONSENT FOR DISCLOSURE OF CONFIDENTIAL INFORMATION FOR SUBSTANCE ABUSE TREATMENT UNDER PENAL CODE SECTION 1210 Form No. L-1207 (Rev. May 26, 2010) Mandatory Form Penal Code 1210 American LegalNet, Inc. www.FormsWorkFlow.com