Form 6-36

Written Authorization for Disclosure of Substance-Abuse Patient Records under 42 C.F.R. Part 2

I, [[name of patient]/[name of parent or guardian of patient]/[name of person authorized to sign in lieu of patient]], authorize:

[Name or general designation of substance-abuse program, entity, or individual permit­ted to make the disclosure] to disclose [kind and amount of information to be disclosed, including an explicit description of the substance-abuse disorder information that may be dis­closed] regarding [name, address, Social Security number, and date of birth of patient] to [name[s], address[es], and telephone number[s] of individuals to whom disclosure is to be made] for [purpose of the disclosure] in Cause No. [full style of suit].

I am [the patient/a parent of the patient/the guardian of the patient/a person authorized to sign in lieu of the patient] whose records are the subject of this authorization.

In accordance with 42 C.F.R. § 2.32, each disclosure made with this written consent must be accompanied by one of the following written statements:

(1) 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 information in this record that identifies a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed 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 (see § 2.31). The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except as provided at §§ 2.12(c)(5) and 2.65; or

(2) 42 CFR part 2 prohibits unauthorized disclosure of these records.

This consent is subject to revocation at any time except to the extent that the program or person permitted to make the disclosure has already acted in reliance on it. If not previously revoked, this consent will terminate on [specific date, event, or condition].

Date of authorization: __________________________

   
[Name of patient/name of parent or
      guardian of patient/name of person
      authorized to sign in lieu of patient]