Release Form

I,

First

Middle

Last

consent to the disclosure of the following information only:

For my

Only choose 1, if for Certificate of completion do not submit until you have received notice that your certificate has been issued

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:

Email Address

Fax Number

Address to Mail 3rd Party

Address Line 1

Address Line 2

City

State

Zip Code

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)

Clear Signature

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