Department of Corrections and Rehabilitation - Operations Manual

Chapter 5 – Adult Custody and Security Operations

Article 17 – Control of Dangerous and Toxic Chemicals

Revised January 26, 2015

A written authorization containing the following:
- The name and signature of the person authorizing the release of information.
- The date of the written authorization.
- The name of the individual or organization that is authorized to release the medical information.
- The name of the designated representative (individual or organization) that is authorized to receive the released information.
- A general description of the medical information that is authorized to be released and purpose of release.
- A date or condition upon which the written authorization shall expire (if less than one year).
A written authorization does not authorize the release of medical information not in existence on the date of written authorization, unless this is expressly authorized, and is not in effect for more from date of written authorization. A written authorization may be revoked in writing at a time.