42 CFR 2.31 Consent (Incoming Disclosure)

 

I authorize Algos Treatment Program and Michael Whitworth, MD to receive protected medical information under the federal statute 42 CFR Part 2 of the patient   (print name):

 

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______________________________________________________________________________________________________

 

 

 

from the individual or organization ___________________________________________________________________________

for the purpose of:

 

 __transfer of care

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 __initiation of specialty care

or

 other…______________________________________________________________________________________

 

Information to be disclosed:

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 __Progress Notes including UDS/UDT, PMP, and counseling results

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 __Entire Chart including detailed psychiatric/drug use history

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Consent is valid through two weeks from the date signed

 

This consent is subject to revocation at any time except to the extent that the program which is to make the disclosure has already taken action in reliance on it. 

 

 

___________________________________________________          _________________________

Signature of Patient                                                                                    Date

 

 

___________________________________________________           _________________________

Signature of parent or guardian (if required)                                              Date