42 CFR Part 2 Authorization Form Template: Patient Consent

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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]

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.

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42 CFR Part 2 Authorization Form Template: Patient Consent

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42 CFR Part 2 Authorization Form Template — quick answers

Reviewed July 2026 Free download, PDF & DOCX

What is a 42 CFR Part 2 authorization form?

A 42 CFR Part 2 authorization form is a written consent form used to authorize the use or disclosure of records connected to substance use disorder diagnosis, treatment, or referral for treatment by a Part 2 program. These rules protect the confidentiality of covered patient records and generally require patient consent unless a specific exception applies.

Why do you need a 42 CFR Part 2 authorization form?

You need a 42 CFR Part 2 authorization form when a patient’s protected substance use disorder records will be shared and no separate legal exception allows the disclosure. A general medical release is not enough for this purpose. The consent must meet the specific requirements of 42 CFR Part 2.

When should you use a 42 CFR Part 2 authorization form?

Use a 42 CFR Part 2 authorization form when a patient wants a Part 2 program or other lawful holder to share covered records with a named person, organization, or class of recipients, including for treatment, payment, or health care operations when proper consent is needed. The regulations specifically address written consent requirements and related disclosures.

How to write a 42 CFR Part 2 authorization form?

Start with the patient’s name, then identify who may disclose the records, what information may be disclosed, and to whom the disclosure may be made. The form should also state the purpose of the disclosure, include the patient’s signature, and include the date signed. If you want, you can also state when the consent expires or ends, and the form should make clear that the patient may revoke consent as allowed by the regulation.

Can AI Lawyer help if providers, patients, and compliance teams all need to review?

AI Lawyer can help by organizing the authorization into clear sections so each reviewer can find the patient details, disclosure scope, recipient information, and signature fields quickly. It can also add internal reference fields, notes, and placeholders that make updates easier to track. A consistent structure helps reduce repeated edits and lowers the chance of missing key details like the records being released, the authorized recipient, or the revocation language before the form is signed.

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