Get Da Form 5018 R

NAME OF MEDCEN/MEDDAC COMMANDER OR DESIGNATED REPRESENTATIVE Type or print DA FORM 5018-R NOV 1981 APD PE v3. ADAPCP CLIENT S CONSENT STATEMENT FOR RELEASE OF TREATMENT INFORMATION For use of this form see AR 600-85 the proponent agency is DCS G-1. SECTION A - CONSENT this I day of client s full name do hereby voluntarily consent to the release of the following information by name of installation ADAPCP pertaining to my identity diagnosis prognosis or treatment from any Army record maintained in connection with alcohol or other drug abuse education training treatment rehabilitatiton or research to for the purpose of namely extent or nature of information to be disclosed SECTION B - EXPIRATION/REVOCATION Check applicable paragraph I understand that this consent automatically expires when the above disclosure action has been taken in reliance thereon and that except to the extent that such action has been taken I can revoke this consent at any time. - Or - For disclosure to civilian criminal justice officials under the provisions of paragraphs 6-9b 4 b and 6-10e 3 AR 600-85 criminal justice system status changes to Further I understand that if my release from confinement probation or parole is conditioned upon my participation in the ADAPCP I cannot revoke this consent until there has been a formal and effective termination or revocation of my release from such confinement probation or parole. SIGNATURE OF CLIENT NAME OF WITNESS Type or print DATE SIGNATURE SECTION C - APPROVAL AUTHORITY FOR RELEASE OF INFORMATION NOTE Other than the MEDCEN/MEDDAC Commander approval authority for release of information may be delegated to the Program Physician or the Clinical Director. In my judgment the release of an evaluation of the present or past status of in the alcohol or other drug treatment and rehabilitation program will not be harmful to him/her. ADAPCP CLIENT S CONSENT STATEMENT FOR RELEASE OF TREATMENT INFORMATION For use of this form see AR 600-85 the proponent agency is DCS G-1. SECTION A - CONSENT this I day of client s full name do hereby voluntarily consent to the release of the following information by name of installation ADAPCP pertaining to my identity diagnosis prognosis or treatment from any Army record maintained in connection with alcohol or other drug abuse education training treatment rehabilitatiton or research to for the purpose of namely extent or nature of information to be disclosed SECTION B - EXPIRATION/REVOCATION Check applicable paragraph I understand that this consent automatically expires when the above disclosure action has been taken in reliance thereon and that except to the extent that such action has been taken I can revoke this consent at any time. SECTION A - CONSENT this I day of client s full name do hereby voluntarily consent to the release of the following information by name of installation ADAPCP pertaining to my identity diagnosis prognosis or treatment from any Army record maintained in connection with alcohol or other drug abuse education training treatment rehabilitatiton or research to for the purpose of namely extent or nature of information to be disclosed SECTION B - EXPIRATION/REVOCATION Check applicable paragraph I understand that this consent automatically expires when the above disclosure action has been taken in reliance thereon and that except to the extent that such action has been taken I can revoke this consent at any time. - Or - For disclosure to civilian criminal justice officials under the provisions of paragraphs 6-9b 4 b and 6-10e 3 AR 600-85 criminal justice system status changes to Further I understand that if my release from confinement probation or parole is conditioned upon my participation in the ADAPCP I cannot revoke this consent until there has been a formal and effective termination or revocation of my release from such confinement probation or parole.