Form 1488 "Consent and Authority to Release Driver's Information to Daodas Treatment Provider" - South Carolina

What Is Form 1488?

This is a legal form that was released by the South Carolina Department of Probation, Parole and Pardon Services - a government authority operating within South Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the South Carolina Department of Probation, Parole and Pardon Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 1488 by clicking the link below or browse more documents and templates provided by the South Carolina Department of Probation, Parole and Pardon Services.

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Download Form 1488 "Consent and Authority to Release Driver's Information to Daodas Treatment Provider" - South Carolina

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South Carolina Department of Probation, Parole and Pardon Services
Consent And Authority To Release Driver’s Information To DAODAS Treatment Provider
NOTE: This form complies with Federal and State standards. When executed, it only authorizes the release of the driver’s
records that are specified below and for the use as specified below. Though the information obtained by use of this form is
held confidentially, under some circumstances it may be made a part of Court records.
NOTE TO TREATMENT PROVIDER: Your possession of this information is subject to Federal confidentiality rules: “This
information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2). The Federal
rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by
the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization
for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the
information to criminally investigate or prosecute any alcohol or drug abuse patient.” (42 CFR § 2.32)
Driver’s Name:
Driver’s License Number:
Date of Birth:
Address:
Treatment Provider:
Address:
Fax number:
Requestor’s Name:
Purpose for which the information is requested:
DAODAS Referral for Driver’s Drug and Alcohol Treatment Assessment
Information Requested:
All violations that resulted in Driver’s referral to the Treatment Provider by DAODAS.
Driver’s Consent and Authorization
I hereby consent to the release of the requested records to the Department of Alcohol and Other Drug Abuse Services
treatment provider listed above, and I authorize the Department of Probation, Parole and Pardon Services / Ignition Interlock
Device Program to release the requested records. I understand that this consent will automatically expire 90 days from the
date of my signature below. I understand that I may withdraw this consent at any time by sending a written notification to the
Ignition Interlock Device Program; I also understand that the requested records may have already been released at the time
of such notice.
Driver’s Signature:
Signature Date:
Expiration Date:
IGNITION INTERLOCK POINT ASSESSMENTS
The following are the violations that resulted in the Driver’s referral for a treatment assessment:
Date of Violation
Type of Violation
Point Assessment
Form 1488 (Template)
Page 1 of 1
South Carolina Department of Probation, Parole and Pardon Services
Consent And Authority To Release Driver’s Information To DAODAS Treatment Provider
NOTE: This form complies with Federal and State standards. When executed, it only authorizes the release of the driver’s
records that are specified below and for the use as specified below. Though the information obtained by use of this form is
held confidentially, under some circumstances it may be made a part of Court records.
NOTE TO TREATMENT PROVIDER: Your possession of this information is subject to Federal confidentiality rules: “This
information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2). The Federal
rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by
the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization
for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the
information to criminally investigate or prosecute any alcohol or drug abuse patient.” (42 CFR § 2.32)
Driver’s Name:
Driver’s License Number:
Date of Birth:
Address:
Treatment Provider:
Address:
Fax number:
Requestor’s Name:
Purpose for which the information is requested:
DAODAS Referral for Driver’s Drug and Alcohol Treatment Assessment
Information Requested:
All violations that resulted in Driver’s referral to the Treatment Provider by DAODAS.
Driver’s Consent and Authorization
I hereby consent to the release of the requested records to the Department of Alcohol and Other Drug Abuse Services
treatment provider listed above, and I authorize the Department of Probation, Parole and Pardon Services / Ignition Interlock
Device Program to release the requested records. I understand that this consent will automatically expire 90 days from the
date of my signature below. I understand that I may withdraw this consent at any time by sending a written notification to the
Ignition Interlock Device Program; I also understand that the requested records may have already been released at the time
of such notice.
Driver’s Signature:
Signature Date:
Expiration Date:
IGNITION INTERLOCK POINT ASSESSMENTS
The following are the violations that resulted in the Driver’s referral for a treatment assessment:
Date of Violation
Type of Violation
Point Assessment
Form 1488 (Template)
Page 1 of 1