My former employer had filed false sworn statements with the D.C. Government alleging that it had determined that I was potentially violent. I had used the employer's false sworn declarations to obtain disability benefits from the U.S. Social Security Administration. It was my good faith belief that violations of federal law had occurred and that the U.S. Department of Justice wrongly refused to investigate these violations.
The George Washington University
Department of Psychiatry and Behavioral Sciences
Consent For Release of Information
I, Gary Freedman, of 3801 Connecticut Ave NW #136 Washington, DC hereby authorize Georgopoulos/Sotsky both M.D. to send Medical Records* to Philip C. Leadroot of U.S. Secret Service for the purpose of Psychological Evaluation in connection with determination by Govt of District of Columbia that I am potentially violent.
I understand that I may inspect this material and that I may request a copy for which there will be no charge. This consent is subject to revocation by me in writing at any time.
I expressly understand and agree that no liability of any nature shall attach to the attending physician, clinician or employee in acting upon this authorization and request.
I further understand that this information cannot be redisclosed without my authorization, and that the law requires this notice:
The unauthorized disclosure of mental health information violates the provisions of the District of Columbia Mental Health Information Act of 1978. Disclosures may only be made pursuant to a valid authorization by the client or as provided in Titles III or IV of the Act. The Act provides for civil damages and criminal penalties for violations.
*Medical records includes any written charts, notes, correspondence, psychological or other test results or reports, test raw data or any other records of any kind in GW's possession
/s/ Gary Freedman
/s/ [illegible witness]
Copies of this consent form must be:
1) provided to the patient
2) included in the patient record
3) accompany disclosures
Division of Ambulatory Care
The H.B. Burns Memorial Building
2150 Pennsylvania Avenue, N.W.
Washington, DC 20037
Telephone (202) 994-4078
Fax (202) 994-6377