Release Form – My DUI Class

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consent to the disclosure of the following information only:

To Be Released To: (Name of 3rd Party)

This can be the County Court, an Attorney, Probation, or a DMV.

I would like this information sent via:

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Address to Mail 3rd Party

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Terms For Use of Release Form

I understand that this consent will terminate 1 year from the discharge of services provided by Right Direction Services LLC or in other action in which consent was given, whichever is later.
I understand that any disclosure of confidential information is governed by federal regulations to the confidentiality of alcohol and drug abuse patient records (42 C.F.R. Part 2). Those regulations permit recipients of confidential information to re-disclose it only in connection with their official duties.

Signature (If minor have parent or guardian sign)

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