I have been informed that the confidentiality of all records and information compiled in reference to my participation in the 4 Seasons Detox and Recovery House Inc. residential program is restricted under the provisions of the following:
State of California, Welfare and Institutions code 5328 through 5330 inclusive; and, United States Code of Federal Regulations, Title 42 2.1 through 2.67 inclusive; and, United States Code of Regulations. Title 42, 205.50; and all other applicable State and Federal laws and regulations relating to confidentiality of all alcohol and/or drug program participant records.
In general these laws and regulations provide that information may not be disclosed to any other party without the participants’ written consent, in advance, which declares the party the party to receive the information, the nature of the information to be released, and limitations of the release.
I authorize 4 Seasons Detox and Recovery House Inc. to provide information regarding my participation in the program for the purpose of;
(1) Monitoring and evaluating the services offered by the program and
(2) Evaluating and monitoring my progress as a program participant.
The following are authorized to receive this information:
State of California, Department of Health Care Services; the County of Ventura, Substance Abuse Prevention and Control Administration; and if applicable because of arrest and/or conviction, the State of California Department of Motor Vehicles and the Court and Probation Department with jurisdiction in my case(s).
I understand that I may revoke my permission to disclose information at any time. This authorization will be in effect unless I have expressly revoked it, from this date through (3) years from date of my last participation in the program.