Release of Information Authorization (42 CFR Part 2)

Release of Information Authorization (42 CFR Part 2)

Issuing Program: [Legal name of Part 2 program]

Form Version: [Version number] | Effective Date: [Date]

Authorization ID: [Unique identifier for tracking and revocation]

Date Generated: [Date and time]

Plain-language statement: This form authorizes the release of substance use disorder treatment information protected under federal law (42 CFR Part 2).

Patient Information

Patient Name: [Full legal name] (Required)

Date of Birth: [MM/DD/YYYY]

Medical Record Number: [MRN]

Address/Phone: [Contact information if needed for matching]

(If patient name is missing or unknown, the form is invalid and must not be used for disclosure.)

Who May Disclose (Authorized Discloser)

Program/Entity Name: [Specific program name] (Required)

Address/Phone/Fax: [Contact information]

(List each Part 2 program separately if multiple programs are authorized. Do not use vague designations unless organizational policy explicitly permits under Part 2.)

Who May Receive (Recipient)

Recipient Name: [Individual or entity name] (Required)

Organization: [Organization name, if applicable]

Address/Contact: [Mailing address, fax, secure email, or portal]

Delivery Method: [paper / electronic PDF / secure fax / HIE / other]

(List each recipient separately if multiple. If recipient is not clearly identified by specific name or valid general designation, the authorization is invalid.)

General Designation Option (If Applicable)

(Include this section only when authorizing disclosure to a class of recipients through an exchange/intermediary and only if your organization can track disclosures and furnish disclosure lists upon patient request. Omit entirely if not applicable.)

Exchange/Intermediary Entity: [Name of exchange or intermediary]

Class of Recipients: [Description of participant class]

Patient Acknowledgement: I understand I may request a list of entities that received my information under this general designation.

Purpose of Disclosure

• [ ] Continuity/coordination of care
• [ ] Treatment
• [ ] Payment/benefits determination
• [ ] Patient request/patient-directed sharing
• [ ] Other: [Specify plain-language purpose]

(Select all that apply. If "Other" is selected, require a plain-language explanation. Do not disclose if purpose is blank. Do not infer purpose from context.)

Information to Be Disclosed

Types of Records Authorized:

• [ ] Diagnosis/problem list related to SUD
• [ ] Treatment plan
• [ ] Progress notes/visit notes
• [ ] Medications/medication history
• [ ] Lab results (e.g., toxicology)
• [ ] Level of care/program participation dates
• [ ] Discharge summary
• [ ] Referral/care coordination communications
• [ ] Other: [Specify record type]

Date Range: From [Start date] to [End date] — OR — Episode of care: [Start date] to [End date]

Required SUD Acknowledgement: This authorization includes information that identifies me as having sought, received, or been referred for substance use disorder assessment or treatment.

(Disclose only categories necessary for the stated purpose. If the description is too vague to determine scope, treat the authorization as invalid. Do not infer scope.)

Patient Limitations and Exclusions (Optional)

Do not disclose to: [Named persons or organizations to exclude]

Exclude the following: [Specific record types or information to exclude]

Release scope: [summary only / full documentation]

Disclosure frequency: [one-time only / ongoing until expiration]

(If a limitation is indicated but details are blank, require completion before signing. Omit section if no limitations specified.)

Expiration

Expires on date: [MM/DD/YYYY]

— OR —

Expires upon event: [Event description, e.g., end of treatment episode, completion of referral]

(One expiration method is required. If expiration is missing, treat the authorization as invalid.)

Right to Revoke

You may revoke this authorization at any time. Revocation does not apply to disclosures already made in reliance on this authorization.

How to revoke: Contact [Program name] at [Phone, address, or portal instructions].

(Revocation instructions must be included for the form to be compliant.)

Redisclosure Notice

Information disclosed under this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal Part 2 regulations. However, recipients who are HIPAA-covered entities are prohibited from using or disclosing information in civil, criminal, administrative, or legislative proceedings against you except as permitted by Part 2.

Patient Acknowledgements

• [ ] I received a copy of this authorization.
• [ ] I understand I can request a list of disclosures made under a general designation (if applicable).

Preferred contact for questions: [Phone or email]

Signature

Patient Signature: ______________________ Date: __________

If Signed by Representative

Representative Name: [Representative full name]

Relationship to Patient: [parent / legal guardian / healthcare proxy / other]

Basis for Authority: [Type of documentation or legal authority]

(Include representative section only if patient did not sign personally.)

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Proceedings Authorization (Separate Consent Required)

(Use ONLY for disclosures involving civil, criminal, administrative, or legislative proceedings or testimony. This authorization must not be combined with the general ROI above.)

Name of Proceeding/Investigation: [Name if known]

Case Number: [Case number if available]

Court/Agency: [Court or agency name]

Parties Authorized to Receive: [Names of authorized parties]

Scope of Records/Testimony: [Specific description of authorized scope]

Expiration: [Date or event tied to proceeding]

Patient Signature: ______________________ Date: __________

SUD Counseling Notes Authorization (Separate Consent Required)

(SUD counseling notes require specific, separate authorization. Signing is NOT required to receive treatment, payment, enrollment, or benefits.)

• [ ] I authorize disclosure of SUD counseling notes.

Specific Recipient: [Recipient name]

Purpose: [Specific purpose for disclosure]

Scope/Date Range: [Specific records and date range]

Expiration: [Date or event]

Patient Signature: ______________________ Date: __________

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Notice to Accompany Disclosure (Cover Sheet)

(Generate and attach this cover notice with every disclosure, plus either a copy of the signed authorization or the scope summary below.)

Patient Name/Identifiers: [Minimum necessary identifiers]

Disclosing Program: [Program name]

Recipient: [Recipient name]

Purpose: [Purpose as authorized]

Categories/Date Range Authorized: [Scope of disclosure]

Authorization Signed: [Date signed] | Expires: [Expiration date or event]

Questions: Contact [Program name] at [Phone number]

Notice format: [standard long form / abbreviated short form]

Administrative Disclosure Log (Internal Use)

(Complete for each disclosure. Retain according to organizational policy and regulatory requirements.)

• Date/Time: [Date and time of disclosure]
• Staff Member: [Name of staff completing disclosure]
• Recipient: [Recipient name]
• Records Sent: [Categories and date range disclosed]
• Delivery Method: [paper / electronic PDF / secure fax / HIE / other]
• Notice/Consent Attached: [ ] Yes