Release Form

Ethics and the Law

Consent for Release of Confidential Information

I, Ž , authorize Œ
(Name of Patient) (Name or general designation of program making disclosure)

to disclose to the following information:
(Name of person or organization to which disclosure is to be made)

.
(Nature of the information to be disclosed, as limited as possible)

The purpose of the disclosure authorized herein is to:
(Purpose of disclosure, as specific as possible)

‘ I understand that my records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and cannot be disclosed without my written consent unless other wise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action had been taken in reliance on it, and that in any event this consent expires automatically as follows:

’
(Specification of the certain date, event, or condition upon which this consent expires)

Dated: ” ” ”

“
Signature of Participant/Consentee

Signature of Parent, Guardian or authorized representative, when required

According to CFR 42 � 2.31, a properly completed consent for release of confidential information must contain each of the following items:

Œ The name or general designation of the program(s) making disclosure;

The name of the individual or organization that will receive the disclosure;

Ž The name of the patient who is the subject of the disclosure;

The purpose or need for disclosure;

How much and what kind of information will be disclosed;

‘ A statement that the patient may revoke the consent at any time, except to the extent that the program has already acted in reliance on it;

’ The date, event or condition upon which the consent expires if not previouly revoked;

“ The signature of the patient (and/or other authorized person); and

� The date on which the consent is signed.

REMEMBER:

This is a legal document. Any change to this document, once the patient has signed it, requires their initials and the date of the amendment as an indication of their approval for the change.

A revocation requires only that a line be drawn through the document, with the word "Revoked", and the date and time of revocation. The patient need not initial a revocation. A patient may request revocation by any means, including the telephone, provided their identity is confirmed.