Ds 451 Form – Fill Out and Use This PDF

New York State Department of Motor Vehicles

DRINKING DRIVER PROGRAM

CONSENT FOR RELEASE OF INFORMATION

INSTRUCTIONS: Giveacopyofthisformtotheparticipant.Programsmustkeepacopyofeachsignedformforsix(6)yearsfrom itsexpirationdate.Pagetwoofthisformmustbecompletedtowithdrawconsent.

PARTICIPANT

Name (Last, First, Middle Initial)

Address (Number and Street)					(Apt. #)
City				State	Zip Code
Date of Birth
/	/	Male	Female

EVALUATIONAGENCYSITE

Name

Address (Number and Street)

Name ofAgency Director

ItisnecessarythatcertaininformationbemadeavailabletotheDepartmentofMotorVehiclessothattheDepartmentwillbeabletodetermine thatallprogramrequirementsaresatisfied.Theextentornatureoftheinformationtobedisclosedisasfollows:

●notationofentryinto,continuationof,orrefusaltoenter,treatment

●reasonsforreportingafailuretosatisfactorilyparticipateintreatment

●beginningandcompletiondatesoftreatment

●nameandlocationoftheevaluationand/ortreatmentagency

●informationprovidedonDMVformDS-449(AlcoholandDrugAbuseRehabilitativeProgramSummary)

FailuretoconsenttothereleaseofthisinformationwillresultinyourbeingdroppedfromtheDrinkingDriverProgram.

I, the undersigned, have read the above and hereby authorize the designated evaluation/treatment agency to disclose/release the required information to the Drinking Driver Program Agency listed below and to the Department of Motor Vehicles. This consent is subject to revocation at any time except to the extent that action has been taken in reliance thereon. In any event, this consent shall expire twelve (12) months from the date of signature, unless a different time period, event or condition is specified below, in which case such time period, event or condition shall apply. I also understand that any disclosure/release is bound by Title 42 of the Code of Federal Regulations governing the confidentiality of alcohol and drug abuse patient records, as well as the Health Insurance Portability andAccountabilityAct of 1996 (“HIPAA”) 45 C.F.R. Parts 160 & 164, and that redisclosure of this information to a party other than those designated above is forbiddenwithoutadditionalwrittenauthorizationonmypart.

Timeperiod,eventorconditionreplacingperiodspecifiedabove:___________________________________________________________

NOTE: Any information released through this form will be accompanied by Form TRS-1 (Prohibition on Redisclosure of Information ConcerningSubstanceAbusePatient),whichcanbeobtainedfromtheNewYorkStateOfficeofAlcoholismandSubstanceAbuseServices.

NameofDrinkingDriverProgramAgency______________________________________________________________________________

I understand that generally the evaluation and/or treatment agency may not condition my treatment on whether I sign a consent form, but that in certain limited circumstances, I may be denied treatment if I do not sign a consent form. I have received a copy of this form, as recognizedbymysignaturebelow.

SignatureofParticipant ➧___________________________________________________________	Date________________________
DS-451 (10/07)	Page 1 of 2

New York State Department of Motor Vehicles

DRINKING DRIVER PROGRAM

WITHDRAWALOF CONSENT FOR RELEASE OF INFORMATION

INSTRUCTIONS: Giveacopyofthisformtotheparticipant.Completionofthispagewithdrawstheconsentindicatedonpageone.

Name of Person or Organization to Which the Disclosure WasAuthorized:

NewYorkStateDepartmentofMotorVehicles

(NameofDrinkingDriverProgramAgency)

Name of Person or Organization Disclosing Information:

(NameofEvaluationand/orTreatmentAgency)

I, the undersigned, hereby withdraw my authorization to disclose information to the above named individual(s)/organization(s), except to theextentthatactionhasalreadybeentakeninrelianceuponit.

I understand that generally the evaluation and/or treatment agency may not condition my treatment on whether I agree to sign a consent form, but that in certain circumstances, I may be denied treatment if I do not sign, or if I withdraw consent. I also recognize that if I withdraw consent, it will result in me being dropped from the Drinking Driver Program. I have received a copy of this form, as recognized bymysignaturebelow.

➧

(SignatureofParticipant)

(Date)

(PrintNameofParticipant)

DS-451 (10/07)

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