42 CFR Part 2 Authorization Form Template: Patient Consent

42 CFR Part 2 Authorization Form Template

Patient Name: [Full Name]
Date of Birth: [Date of Birth]
Address: [Address]
City, State, ZIP Code: [City, State, ZIP Code]
Phone Number: [Phone Number]
Email Address: [Email Address]

Date: [Date]

Part 2 Program or Lawful Holder: [Program / Provider / Organization Name]
Address: [Address]
City, State, ZIP Code: [City, State, ZIP Code]

1. Patient Authorization

I, [Patient Full Name], authorize the use or disclosure of my records that are protected under 42 CFR Part 2, subject to the terms of this authorization.

This authorization applies to records maintained by:

[Part 2 Program / Provider / Organization Name]

2. Person or Entity Authorized to Disclose

The following person, program, or organization is authorized to make the disclosure:

[Name of Program, Provider, Office, or Other Lawful Holder]

Address: [Address]

3. Information to Be Disclosed

The records or information authorized for use or disclosure are:

☐ admission or discharge information
☐ assessment or intake records
☐ diagnosis information
☐ treatment records
☐ medication information
☐ attendance or participation information
☐ billing or payment records
☐ laboratory or testing information
☐ other: [Describe]

Description of records to be disclosed:

[Describe the information in a specific and meaningful way]

4. Recipient of Disclosure

The records may be disclosed to the following person(s) or organization(s):

[Recipient Name or Specific Identification]

Address: [Address]

If a class of recipients is allowed, describe it here:

[Describe class of persons, if applicable]

5. Purpose of Disclosure

The purpose of this use or disclosure is:

☐ treatment
☐ payment
☐ health care operations
☐ legal matter
☐ insurance or benefits matter
☐ personal request of the patient
☐ other: [Describe]

6. Expiration or End of Authorization

This authorization shall remain in effect until:

☐ [Specific Date]
☐ completion of the following event: [Describe]
☐ revocation by the patient, to the extent allowed by law and the status of any action already taken in reliance on this authorization

7. Revocation Statement

I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it or as otherwise allowed by applicable law.

Written revocation may be sent to:

[Program / Provider / Contact Name]
[Address]
[Email Address, if applicable]

8. Patient Acknowledgment

I understand that this form authorizes the use or disclosure of records protected by 42 CFR Part 2. I understand the scope of this authorization and sign it voluntarily.

I understand that a general authorization for the release of medical or other information is not sufficient for this purpose.

9. Signature

Patient Signature: __________________________
Name: [Patient Full Name]
Date: [Date]

If signed by a personal representative:

Representative Name: [Full Name]
Relationship / Authority: [Parent / Guardian / Personal Representative / Other]
Signature: __________________________
Date: [Date]

10. Optional Witness or Staff Confirmation

Witness or Staff Member Name: [Full Name]
Title: [Title]
Signature: __________________________
Date: [Date]

11. Notice Accompanying Disclosure

If records are disclosed under this authorization, the disclosure may need to be accompanied by the applicable notice regarding restrictions on further use or disclosure under 42 CFR Part 2.