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Substance Abuse Treatment Consent (42 CFR Part 2)

Specialized consent form for disclosure of substance use disorder treatment records under the stricter protections of 42 CFR Part 2.

PDF TemplateUse the instructions below to complete this form

Instructions

42 CFR Part 2 records require more specific consent than standard HIPAA authorization. Include the specific name or description of the program making the disclosure, the name of the individual or organization receiving the information, the purpose of the disclosure, how much and what kind of information will be disclosed, the patient's right to revoke, and the expiration date. Include the required prohibition on re-disclosure statement.