Lowndes County, GA · Lowndes County
Consent for the Release of Confidential Information
This consent form lets a Lowndes County DUI Court participant authorize release of specified personal, treatment, and testing information to listed agencies and providers.
At a glance
- Issued by
- City of Lowndes County · Lowndes County, Lowndes County, Georgia
- Notarization
- Not required: file this form without a notary.
- Official source
- lowndescounty.com
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
The form authorizes communication between the Lowndes County DUI Court and treatment providers, probation, attorneys, a drug test lab, and other agencies. It describes information that may be disclosed, including treatment attendance, diagnosis, and drug test results, and notes that consent may be revoked subject to actions already taken in reliance on it. The participant signs and dates the form, and a witness also signs and dates it.
Who needs it
A Lowndes County DUI Court participant who consents to the information sharing and open court participation described in the form should complete it.
How to submit it
Submit it to the county department named on the form; check the county website for current contact details.
About notarization
This document is signed without a notary; the participant and a witness each sign and date it.
How to submit this form
- 1
Download the Form
Download the Consent for the Release of Confidential Information.
- 2
Review the Consent
Read the information-sharing terms and the description of information that may be disclosed.
- 3
Sign and Date
The participant signs and dates the form; a witness also signs and dates it.
- 4
Submit to the County
Submit it to the county department named on the form; check the county website for current contact details.
Frequently asked questions
- What does this consent form authorize?
- It authorizes communication between the Lowndes County DUI Court and listed providers and agencies about information such as treatment attendance, diagnosis, cooperation, prognosis, and drug test results.
- Do I need a notary for the Consent for the Release of Confidential Information?
- No. The document has signature and date lines for the participant and a witness, but no notary block.
- How do I submit the consent form?
- The document does not give submission instructions. Submit it to the county department named on the form and check the county website for current contact details.