Appendix B—Sample Forms and Agreements To Facilitate Collaborative Efforts Between the Substance Abuse Treatment and Welfare Systems

Sample Form #1:
Patient Consent for the Release of Confidential Information

Patient Consent for the Release of Confidential Information I, Jane Doe , authorize (NAME OF PATIENT)
ABC Treatment Program
(NAME OR GENERAL DESIGNATION OF PROGRAM MAKING DISCLOSURE)
to disclose to Mary Roe or another TANIFF counselor
(NAME OF PERSON OR ORGANIZATION TO WHICH DISCLOSURE IS TO BE MADE)
the following information: treatment my attendance and compliance in substance abuse
(NATURE OF THE INFORMATION, AS LIMITED AS POSSIBLE)
The purpose of the disclosure authorized herein is to: Assist the Hill Co. Dept of Welfare to determine my eligibility for benefits and/or to evaluate my readiness/ability to participate in a training program.
(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 otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically as follows:
(SPECIFICATION OF THE DATE, EVENT, OR CONDITION UPON WHICH THIS CONSENT EXPIRES)
Dated:
(Signature of Participant)
(Signature of Parent, Guardian or Authorized Representative, When Required)

Sample Form #2:
Multiparty Consent Form

Multiparty Consent Form I, , authorize
(NAME OF PATIENT)

(NAME OR GENERAL DESIGNATION OF PROGRAM MAKING DISCLOSURE)
to disclose to: (the following persons or organizations)
1.

2.

3.

The purpose of the disclosure authorized herein is to: permit the participants of a case conference concerning my case to exchange information with one another.
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 otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically as follows:
(SPECIFICATION OF THE DATE, EVENT, OR CONDITION UPON WHICH THIS CONSENT EXPIRES)
(DATE) (SIGNATURE OF PARTICIPANT)
(SIGNATURE OF PARENT, GUARDIAN OR AUTHORIZED REPRESENTATIVE IF REQUIRED)
B-3

Sample Form #3:
Prohibition on Redisclosure of Information Concerning Client in Alcohol or Drug Abuse Treatment
The following notice accompanies a disclosure of information concerning a client in alcohol/drug abuse treatment, made to you with the consent of such client.
Prohibition on Redisclosure of Information
Concerning Client in Alcohol or Drug Abuse Treatment

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 this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains 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. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
Sample Form #4:
Qualified Service Organization Agreement

Qualified Service Organization Agreement XYZ Service Center ("the Center") and
(NAME OF THE PROGRAM)
("the Program") hereby enter into a qualified service organization agreement, whereby the Center agrees to provide
(NATURE OF SERVICES TO BE PROVIDED)
Furthermore, the Center:

(1)
acknowledges that in receiving, storing, processing, or otherwise dealing with any information from the Program about the patients in the Program, it is fully bound by the provisions of the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2; and

(2)
undertakes to resist in judicial proceedings any effort to obtain access to information pertaining to patients otherwise than as expressly provided for in the Federal confidentiality regulations, 42 CFR Part 2.

Executed this day of , 199 .

President Program Director
XYZ Service Center [Name of the Program]
[address] [address]

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