42 CFR 2.31 Consent (Outgoing Disclosure)

 

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

 

 _______________________________________________________________________________________________________

 

 

to the individual or organization ______________________________________________________________________________

 

 

for the purpose of:

 

 __counseling by a licensed psychologist, psychiatrist, or social worker

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__ government agency compliance monitoring

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 __insurance coverage or pharmacy issue

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 __transfer of care

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 __other…     

 

Information to be disclosed:

 

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

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 __Entire Chart including detailed psychiatric/drug use history

 

Consent is valid through:

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 __Two weeks from the date signed

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 __As long as continuous (monthly or bimonthly) counseling is maintained

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 __As long as pharmacy or insurance coverage issues occur requiring Algos interaction with these entities to attempt to provide uninterrupted prescriptions

 

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