Approved,  SCAO

STATE OF MICHIGAN

JUDICIAL DISTRICT

WAIVER OF PRIVILEGE
AGAINST DISCLOSURE
(Alcohol/Substance Abuse Treatment)

CASE NO.

Court    address

Court    telephone    no.

THE PEOPLE OF

The State of Michigan

Defendant name and address

v

Program name:

Director or designee:

Release to:

District Court

I, the defendant in this case, waive my privilege against disclosure regarding alcohol/substsance abuse treatment and authorize the

above program, its director or designee to release any and all information and records concerning my attendance, progress, services

received, counseling reports, conduct appraisals, and recommendations for additional services to the district court listed above for

the purpose of assisting the court in an appropriate disposition of this case.

This authorization will remain in effect until the purpose for which it was given no longer exists.

Date

Defendant's  signature

Witness

DC 214   (11/83)   WAIVER OF PRIVILEGE AGAINST DISCLOSURE (Alcohol/Substance Abuse Treatment)



Waiver of Privilege Against Disclosure (Alcohol/Substance Abuse Treatment)

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Michigan state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

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About This Form:

• Sourced from www.courts.michigan.gov/forms-criminal-misdemeanor (2023-03)
• Page(s): 1
• Fields(s): 15
• Average fields per page: 15
• Reading Level: Grade 10
• LIST Grouping(s): CO-07-00-00-00, CO-00-00-00-00.

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