Bridging the justice gap in New York

AUTHORIZATION FOR POSSESSION AND USE OF RECORDS

I authorize                                 or his/her/its agents to receive, possess, copy and inspect any of the following records concerning me:

Department of Correctional Services ("DOCS") inmate and medical and dental records; New York State Division of Parole records; medical and dental records in the possession of any physician, clinic, hospital or other institution providing physical or mental health service; criminal history records retained by the New York State Division of Criminal Justice Services; any police department and/or the Federal Bureau of Investigation records.

I waive my rights to the confidentiality of such records and consent to the use of information contained therein by                                                             or his/her/its agents in the course of providing assistance to me. This authorization/release is valid for one year from the date signed. I understand that I may revoke this authorization at any time by written notice to either                                         or DOCS.

I have read all of the above before signing the authorization form.