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Get Vermont Project Crash Completion Form

STATE OF VERMONT PROJECT CRASH RELEASE OF CONFIDENTIAL INFORMATION I date of birth // authorize Project CRASH to disclose information about the facts of my enrollment current status and completion of the Project CRASH School/therapy program to and to obtain information to assist in determining completion of the Project CRASH School/therapy program from The Vermont Department of Motor Vehicles Applicable Vermont District or Superior Court s Court Diversion and/or Teen Alcohol Safety Program Please check any additional agencies/persons to whom information may be disclosed and received Spouse and/or other family member MUST list names Attorney MUST give name or agency Department of Motor Vehicles in a State other than Vermont MUST give department and address Counselor/Treatment facility MUST give name of facility and/or counselor Other agency or person The purpose of the disclosure authorized herein is to Satisfy the conditions of my probation/parole and/or Satisfy conditions for the reinstatement of my driving privileges and/or Other. I understand that my alcohol and/or drug treatment records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse patient Records 42 C. F*R* part 2 and the Health Insurance Portability and Accountability Act of 1996 HIPAA 45 C. F*R* Pts. 160 164 and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent in writing at any time except to the extent that action has been taken in reliance on it and that in any event this consent expires automatically upon my release from probation/parole and/or upon reinstatement of my driving privileges. Signature of Participant Date Department of Health Project CRASH 108 Cherry Street PO Box 70 Burlington VT 05402-0070 Telephone 802-651-1574. I understand that my alcohol and/or drug treatment records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse patient Records 42 C. F*R* part 2 and the Health Insurance Portability and Accountability Act of 1996 HIPAA 45 C. F*R* Pts. F*R* part 2 and the Health Insurance Portability and Accountability Act of 1996 HIPAA 45 C. F*R* Pts. 160 164 and cannot be disclosed without my written consent unless otherwise provided for in the regulations. 160 164 and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent in writing at any time except to the extent that action has been taken in reliance on it and that in any event this consent expires automatically upon my release from probation/parole and/or upon reinstatement of my driving privileges. I also understand that I may revoke this consent in writing at any time except to the extent that action has been taken in reliance on it and that in any event this consent expires automatically upon my release from probation/parole and/or upon reinstatement of my driving privileges. Signature of Participant Date Department of Health Project CRASH 108 Cherry Street PO Box 70 Burlington VT 05402-0070 Telephone 802-651-1574.

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