Treatment Record Request

The Alcoholism and Chemical Dependency Programs abides by the federal statutes 42CFR Part 2 and the HIPPA (Health Insurance Portability and Accountability Act of 1996) protections of electronic files in regards to confidentiality requirements specific to the protection of material included in the treatment record. Release of program participant information, current or former, to anyone outside of Adult Corrections/ Prisons without the written authorization of the participant or a properly executed court order is prohibited.

Prison Records
Past program participants who received treatment services within a prison facility may self-request verification of their completed program hours by:

Completing the Authorization for Release of Information form linked below. Please print legibly when filling in the form.

Mailing the original Authorization for Release of Information form to:

Alcoholism and Chemical Dependency Programs
Quality Assurance Specialist
2020 Yonkers Road
Raleigh, N.C. 27699-4211

DART Cherry or Black Mountain Treatment Center for Women Records
Past program participants who received treatment services at either DART Cherry or Black Mountain may request verification of their completed program hours by:

Completing the Authorization for Release of Information form linked below. Please print legibly when filling in the form.

Mailing the original Authorization for Release of Information form to the appropriate facility below:

Black Mountain Substance Abuse Treatment Center for Women
Substance Abuse Program Director
1449 North Fork Road
Black Mountain, N.C. 28711

DART Cherry
Substance Abuse Program Director
P.O. Box 247
Goldsboro, N.C. 27533-0247

Other Agencies and Treatment Providers
Past program participants who are involved with official agencies or entities to include: the Division of Social Services (DSS), Vocational Rehabilitation, Administrative Office of the Courts, Federal Probation, a legal attorney, or an authorized substance abuse treatment provider may have the entity request the verification of the completed program hours. The verification of completed hours will be mailed direct to the requesting entity after submitting their request as follows:

Complete a properly executed Authorization for Release of Information form in compliance with federal regulations.

Mail or fax the Authorization for Release of Information form to:

Alcoholism and Chemical Dependency Programs
Quality Assurance Specialist
2020 Yonkers Road
Raleigh, N.C. 27699-4211
Fax: (919) 324-6031

AA/NA Records
The Alcoholism and Chemical Dependency Programs cannot respond to requests for AA/NA participation at a prison facility. Follow the procedure below to request AA/NA participation information:

If the requestor is no longer under Adult Corrections/ Prisons supervision, requests for AA/NA meeting attendance should be submitted to the Prison's Director of Substance Abuse Programs at (919) 838-4000.

If the requestor is inquiring about an inmate who is still under state prison supervision, the requestor should contact the inmate's Prison Case Manager where the inmate is housed.

If the requestor is on probation with Community Corrections, the requestor should contact the offender's probation/parole officer.

Request Form: Authorization for Release of Information

 

 

 

« this page last modified 03/12/15 »