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Run: 42 CFR Part 2 Substance Use Disorder Records Release

This 42 CFR Part 2 Substance Use Disorder Records Release template captures patient consent, recipient details, record scope, expiration, and redisclosure ac...

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Consent Notice and Submission Terms

Authorization Notice (required)

I have read and understand the authorization notice above (required)

Yes No N/A

Submission Type (required)

Patient Identification

Patient Full Name (required)

Date of Birth

Collect only if needed to accurately identify the patient record.

Medical Record Number

Optional identifier if used by your organization to locate the correct record.

Phone Number

Disclosing Program and Recipient

Disclosing Program / Facility Name (required)

Recipient Type (required)

Recipient Name (required)

Recipient Department or Attention To

Recipient Contact Information

Include address, fax, secure email, or other contact details used for disclosure.

Records to Be Disclosed

Information Categories to Disclose (required)

Describe Other Information (required)

Records From Date

Records Through Date

Specific Program Episode or Service Period

Use this field if the release should be limited to a specific episode of care.

Purpose and Expiration

Purpose of Disclosure (required)

Authorization Expires (required)

Expiration Date (required)

Expiration Event (required)

Describe the event that will end this authorization.

Other Expiration Details (required)

Patient Rights, Signature, and Acknowledgment

I understand I may revoke this authorization in writing except to the extent action has already been taken in reliance on it (required)

Yes No N/A

I understand that records protected by 42 CFR Part 2 may not be redisclosed without my consent except as permitted by law (required)

Yes No N/A

Patient Signature (required)

Signature Date (required)

Representative Name

Relationship to Patient

Witness Name

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Email (required)

Your name (optional)

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