Sees-the-Day, Inc. Consent for the Release of Confidential Information Probation and Insurance
I, _______________________________ authorize Sees-the-Day, Inc. to disclose to _________________________________________ the following information:
(1)	Whether or not the resident is in treatment
(2)	Prognosis of the resident
(3)	The nature of the project
(4)	A brief discussion of progress of the resident
(5)	Short statement as to whether or not there has been a relapse into drug or alcohol abuse and frequency of such relapse.
For the purpose of:
_____	Determination of treatment needs
_____	Continuity of care
_____	Coordination of services
_____	Compliance with probation/parole regulations
_____	Obtaining assessment/evaluation information
_____	Other ___________________________
For those on Probation and Parole, the Pennsylvania Department of Health, ODAP Policy as of October, 1992, mandates the above-restricted release of information.
I understand that my records are protected under the Federal Confidentiality regulations and cannot be disclosed without my express written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it, e.g., probation/ parole, etc. In addition, that in any event this consent automatically expires three (3) months following discharge from treatment.
Specification of the date, event, or condition upon which this consent expires:
______________	_____________________________
Date	Resident
______________	_____________________________
Date	Witness
I have been offered a copy of this consent form and ___ Yes, I accepted the offer and received a copy; or ___ No, I declined the offer.
	_____________________________
	Resident