SUD Confidentiality & Consent Documentation Note (42 CFR Part 2)

Part 2 Protected—Access and Redisclosure Restrictions Apply

Date/Time: [Date and time of documentation]

Author/Role: [Author full name and credential/role]

Patient Name: [Patient full name]

MRN/DOB: [Medical record number] / [Date of birth]

Encounter Type: [inpatient / outpatient / telehealth]

Setting: [Facility or program name]

Purpose & Applicability

Trigger event: [Trigger event and operational goal] (State succinctly, e.g., new intake, care coordination request, patient request to share, consent update/revocation.)

Part 2 applicability: [Yes / No / Requires privacy review—do not disclose] (If unclear, select "Requires privacy review—do not disclose" as safety stop.)

Decision-making capacity: [Yes / No]

Authorized representative: [Representative name] — [Authority basis] (Only include if capacity is No.)

Consent Discussion Summary

Discussion status: [completed / declined / unable to complete] (If declined or unable to complete, document rationale and that no disclosure will be made; omit checklist below.)

• Part 2 protections explained: [confirmed / not discussed]
• Purpose of disclosure explained: [confirmed / not discussed]
• Recipients reviewed: [confirmed / not discussed]
• Redisclosure risks explained: [confirmed / not discussed]
• Right to refuse explained: [confirmed / not discussed]
• Right to revoke explained (including how): [confirmed / not discussed]
• Expiration conditions explained: [confirmed / not discussed]
• Right to request restrictions explained: [confirmed / not discussed]
• Questions answered: [yes / no]

Comprehension & voluntariness: [Brief narrative confirming voluntariness and patient comprehension, including method used to confirm understanding]

Consent Outcome & Specification

Consent status: [Consent granted / Consent declined / Deferred / Partial consent / Consent updated or renewed / Consent revoked / Exception used (no consent required)]

Consent Details

(Include only if consent granted. If any required element is absent, document "Consent incomplete—disclosure not permitted" and note follow-up steps.)

• From whom: [Disclosing party name or class]
• To whom: [Named individual(s)/entity(ies) or defined class; if intermediary/HIE, include intermediary name and participant designation]
• Information authorized: [Specific categories] — [Date range: start to end] — SUD counseling notes: [excluded / separately consented] — Minimum necessary: [confirmed]
• Purpose: [Specific purpose or "treatment, payment, and health care operations"]
• Expiration: [Date or event]
• Revocation process: [How patient may revoke and when revocation becomes effective]
• Signature: [wet / e-sign] — [Signature date/time] (If signed by representative, include representative name and authority basis.)

Consent Declined

(Include only if consent declined.)

[Document that consequences were explained without coercion and that no disclosure will be made]

Consent Deferred or Partial

(Include only if consent deferred or partial.)

Scope/limitations: [What is deferred or limited]

Pending steps: [Next actions to complete consent or clarify scope]

Consent Updated, Renewed, or Revoked

(Include only if consent updated, renewed, or revoked.)

Change type: [update / renewal / revocation]

Details: [What changed, method received, effective date/time]

Actions taken: [Notifications sent, steps to implement change] (Include only if revocation.)

Exception Used (No Consent Required)

(Include only if exception used, e.g., medical emergency.)

• Recipient: [Name and affiliation]
• Discloser: [Name]
• Date/time: [Date/time of disclosure]
• Exception basis: [Nature of emergency or exception]

Attachments & Attestation

Executed written consent: [attached / linked / not available] — Consent ID/version: [if applicable]

Copy provided to patient: [Yes / No] — [paper / portal / secure email] — [Date/time]

Special consents: [SUD counseling notes consent status; SUD proceedings consent status] (Note if separate documents were executed or if not applicable.)

Clinician attestation: I attest that identity was verified, capacity/authority was confirmed, informed discussion was completed as documented, and consent was captured with all required elements (or disclosure was not made due to deficiency).

Clinician Signature: [Name, credentials] — [Date/time]