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Consent for DOT Records
Substance Abuse Professionals of Texas
Clayton Sponhaltz, LCDC, NCACI, SAP
18838 Stone Oak Pkwy, Ste. 103
San Antonio, TX 78258
substanceabusepro@gmail.com
210.846.1819

Authorization for Disclosure of Health Information
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Date of birth *
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Name *
Social Security Number *
Employer Name *
Employer Address *
Employer Phone *
Employer Email Address *
Today's Date *
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By DIGITALLY SIGNING this document  I am requesting that Clayton Sponhaltz send my DOT INITIAL REORT, COMPLIANCE REPORT, RTD TEST PLAN, AND FOLLOWUP TEST PLAN to the above named employer.
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Name of Designated Employee Representative  *
This information has been disclosed to you from records whose confidentiality is protected by Federal Law.
Federal regulations 42 CFR Part 2 prohibit you from making further disclosure of it without the specific
written consent of the person to whom it pertains, or as otherwise permitted by such regulations, as general
authorization for the release of medical or other information is NOT sufficient for this purpose.
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