CONSENT TO RELEASE RECORDS CONTAINING SUBSTANCE ABUSE INFORMATION 42 CFR
Part 2 and HIPAA
REMEMBER: Information disclosed pursuant to patient consent must be accompanied by the notice
prohibiting redisclosure.
I, ,
[patient’s name]
Authorize: The Detox Center II LLC DBA kandela Recovery Center
[name or general designation of individual or entity making the disclosure]
to disclose the following:
1. This information will include the following:
Intake/ Consent Forms. Treatment Plans
Labs Case Management
Vitals Discharge Planning/
Documentation
Doctor’s Orders Full Chart (Applicable
for third party requests)
Medical Evaluations
to
[name of recipient]
for the purpose of .
[describe the purpose of the disclosure as specific as possible]
Medical Records will be sent electronically via
email: Email address:
I understand that if records requested are being sent directly to patient, as opposed to an authorized
third party, a partial chart will be sent and will not include clinical notes or evaluations.
I understand that my substance use disorder records are protected under the Federal regulations
governing Confidentiality and Substance Use Disorder Patient Records, 42 C.F.R. Part 2, and the
Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. pts 160 & 164, and
cannot be disclosed without my written consent unless otherwise provided for by the regulations.
I understand that I may revoke this authorization at any time except to the extent that action has been
taken in reliance on it. Unless I revoke my consent earlier, this consent will automatically expire one
year after release was signed and date.
.
[describe date, event, or condition upon which consent will expire, which must be no longer
than reasonably necessary to serve the purpose of this consent]
I understand that I might be denied services if I refuse to consent to a disclosure for purposes of
treatment, payment, or health care operations, if permitted by state law. I will not be denied services if I
refuse to consent to a disclosure for other purposes.
I have been provided a copy of this form.
Signature of Patient Date
