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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

__ government agency compliance monitoring

 __insurance coverage or pharmacy issue

 __transfer of care

 __other…     

 

Information to be disclosed:

 

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

 __Entire Chart including detailed psychiatric/drug use history

 

Consent is valid through:

 __Two weeks from the date signed

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

 __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

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