[Code of Federal Regulations]

[Title 42, Volume 1]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR2.31]



[Page 18-19]

 

                         TITLE 42--PUBLIC HEALTH

 

    CHAPTER I--PUBLIC HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN 

                                SERVICES

 

PART 2_CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE PATIENT RECORDS--Table of 

Contents

 

              Subpart C_Disclosures With Patient's Consent

 

Sec.  2.31  Form of written consent.





    (a) Required elements. A written consent to a disclosure under these 

regulations must include:

    (1) The specific name or general designation of the program or 

person permitted to make the disclosure.

    (2) The name or title of the individual or the name of the 

organization to which disclosure is to be made.

    (3) The name of the patient.

    (4) The purpose of the disclosure.

    (5) How much and what kind of information is to be disclosed.

    (6) The signature of the patient and, when required for a patient 

who is a minor, the signature of a person authorized to give consent 

under Sec.  2.14; or, when required for a patient who is incompetent or 

deceased, the signature of a person authorized to sign under Sec.  2.15 

in lieu of the patient.

    (7) The date on which the consent is signed.

    (8) A statement that the consent is subject to revocation at any 

time except to the extent that the program or person which is to make 

the disclosure has already acted in reliance on it. Acting in reliance 

includes the provision of treatment services in reliance on a valid 

consent to disclose information to a third party payer.

    (9) The date, event, or condition upon which the consent will expire 

if not revoked before. This date, event, or condition must insure that 

the consent will last no longer than reasonably necessary to serve the 

purpose for which it is given.

    (b) Sample consent form. The following form complies with paragraph 

(a) of this section, but other elements may be added.





[[Page 19]]





1. I (name of patient) [squ] Request [squ] Authorize:

2. (name or general designation of program which is to make the 

disclosure)

[fxsp0]_________________________________________________________________

3. To disclose: (kind and amount of information to be disclosed)

[fxsp0]_________________________________________________________________

4. To: (name or title of the person or organization to which disclosure 

is to be made)

[fxsp0]_________________________________________________________________

5. For (purpose of the disclosure)

[fxsp0]_________________________________________________________________

6. Date (on which this consent is signed)

[fxsp0]_________________________________________________________________

7. Signature of patient

[fxsp0]_________________________________________________________________

8. Signature of parent or guardian (where required)

[fxsp0]_________________________________________________________________

9. Signature of person authorized to sign in lieu of the patient (where 

required)

[fxsp0]_________________________________________________________________

10. 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. If not previously revoked, this consent 

will terminate upon: (specific date, event, or condition)



    (c) Expired, deficient, or false consent. A disclosure may not be 

made on the basis of a consent which:

    (1) Has expired;

    (2) On its face substantially fails to conform to any of the 

requirements set forth in paragraph (a) of this section;

    (3) Is known to have been revoked; or

    (4) Is known, or through a reasonable effort could be known, by the 

person holding the records to be materially false.



(Approved by the Office of Management and Budget under control number 

0930-0099)