IDRP Release of Confidential Information

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1. First Name *This question is required.

2. Middle Initial/Middle Name

3. Last Name *This question is required.

4. Suffixes (i.e. Jr., III)

5. Date of Birth (mm/dd/yyyy) This question requires a valid date format of MM/DD/YYYY.

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6. I authorize the IDRP to communicate with me via email and understand that these communications cannot be guaranteed as secure or confidential. *This question is required.

7. Email address This question requires a valid email address.

7. I authorize:

The Impaired Driver Rehabilitation Program (IDRP),
The Vermont Department of Motor Vehicles (DMV),
Applicable Vermont District or Superior Court(s),
The Vermont Department of Corrections, including Probation & Parole (if applicable),
Court Diversion and/or Teen Alcohol Safety Program (if applicable)

to communicate with and disclose to one another information about the facts of my IDRP enrollment, status, and completion of the IDRP education/treatment program. The amount of information disclosed will be the minimum amount necessary to satisfy the purpose. This information may include substance use treatment information for the purpose of determining:

Completion of requirements for the reinstatement of my driving privileges, and/or
Compliance with the conditions of my probation/parole

Note: If you select "No", the IDRP can not send your IDRP completion to the DMV. The IDRP does not share or disclose information without your authorization. *This question is required.