Authorization for Release of Records

1Participant (person whose records will be released)

The individual enrolled in the court-ordered program.

Full legal name *

Date of birth

Phone

Email *

2Program & court matter

Program enrolled

Case / docket number

Jurisdiction (county / state)

Court / referring authority

3Information to be released, and to whom

A specific, meaningful description of the information authorized for release (45 CFR §164.508(c)(1)(i)).

Information authorized for release Enrollment confirmation (program, start date) Attendance & seat-time records Completion status & date Certificate of completion Pre/post assessment or behavioral-evaluation results Reflection journal / Transformation Evidence Summary

Release to — name

Role

Organization / court

Recipient email

Recipient mailing address (if mailed)

Purpose of the disclosure

4Authorization & your rights

I authorize GraceRoot Institute to use and disclose the information described above to the recipient named above, for the stated purpose. I understand and agree that:

Voluntary. This authorization is voluntary. GraceRoot Institute will not condition my enrollment in or completion of the program on whether I sign it. However, GraceRoot cannot release my records to the court or a third party without this authorization (or a valid court order/subpoena).
Right to revoke. I may revoke this authorization at any time by writing to support@graceroot.institute. Revocation will not apply to information already released in reliance on this authorization before GraceRoot received my written revocation.
Redisclosure. Information disclosed under this authorization may be redisclosed by the recipient and may then no longer be protected by federal privacy law (45 CFR §164.508(c)(2)(iii)). Once records are filed with a court, they may become part of the court record.
Nature of the records. GraceRoot programs are educational. The records released are program participation and completion records — they are not a clinical diagnosis, treatment record, or forensic evaluation unless expressly stated. Any reflection material I choose to authorize (above) is my own written work and may be shared with the court if I check that box.
Limits of confidentiality. Educational program communications are not privileged. Nothing in this program is a substitute for legal advice, and GraceRoot cannot advise me on whether releasing any item may affect my legal matter — I should consult my attorney before authorizing release of reflective material.

This authorization expires on the date or event I specify below. If none is specified, it expires one (1) year from the date signed, or upon my court matter's conclusion, whichever is earlier (45 CFR §164.508(c)(1)(v)).

Expiration date or event

Please confirm * I have read and understand the authorization and my rights above. I understand this authorization is voluntary and that I may revoke it in writing. I understand that once released, information may be redisclosed and may no longer be protected.

5Signature

Typing your full legal name below serves as your electronic signature (E-SIGN / UETA).

Electronic signature (type full legal name) *

Date *

If the participant is a minor or under guardianship, the parent or legal guardian must sign and note their authority.

This form is modeled on the HIPAA Privacy Rule authorization standard (45 CFR §164.508) and is provided for participant convenience. It is not legal advice. GraceRoot Institute recommends that participants consult their own attorney, and that this template be reviewed by legal counsel before institutional use.

1Participant (person whose records will be released)

2Program & court matter

3Information to be released, and to whom

4Authorization & your rights

5Signature

Program Clarity