On March 21, 2017, amendments to the federal substance use disorder confidentiality regulations, known as 42 C.F.R. Part 2, took effect. LAC is currently updating its sample forms and materials for use by substance use programs, and has removed from this page all samples that do not comply with the amended regulations. Below are the sample forms and materials that comply with the new regulations. Please continue to check this page for new, updated sample forms and materials, and please subscribe to our updates to receive information about the new edition of LAC’s seminal book, Confidentiality and Communication: A Guide to the Federal Drug & Alcohol Confidentiality Law and HIPAA, which will be published soon.

  • Sample Consent – Basic (Disclosure Using General Designation). Coming soon.
  • Sample Consent – Child Welfare. Sample consent form for the release of a patient’s confidential alcohol or drug treatment information between a treatment program and a child welfare agency. This form is currently being updated to comply with the Final Rule that became effective on March 21, 2017.
  • Sample Consent – Criminal Justice / 42 C.F.R. Part 2 only. Sample consent form for the release of a patient’s confidential alcohol or drug treatment information to a criminal justice agency, when there is no HIPAA court order in placeThis form is currently being updated to comply with the Final Rule that became effective on March 21, 2017.
  • Sample Consent – Criminal Justice / HIPAA & 42 C.F.R. Part 2. Sample consent form for the release of a patient’s confidential alcohol or drug treatment information to a criminal justice agency, when there is a HIPAA court order in place. This form is currently being updated to comply with the Final Rule that became effective on March 21, 2017.
  • Sample Qualified Service Organization/Business Associate Agreement (QSO/BA Agreement). A sample agreement between an alcohol or drug treatment or prevention program and a Qualified Service Organization or Business Associate. This form is currently being updated to comply with the Final Rule that became effective on March 21, 2017.
  • Sample Court Order. An example of a court order that would allow an alcohol or drug treatment program that is covered by both 42 C.F.R. Part 2 and HIPAA to use the irrevocable criminal justice consent form permitted under 42 C.F.R. § 2.35 for a particular patient. Adapted from a court order drafted by the New York State Office of Court Administration.
  • Sample Standing Court Order. An example of a standing court order that would allow an alcohol or drug treatment program covered by both 42 C.F.R. and HIPAA to use the irrevocable criminal justice consent form permitted under 42 C.F.R. § 2.35 for all patients of that particular program. Adapted from a court order drafted by the New York State Office of Court Administration.

Important reminder: State laws and court rules may affect the content of court or administrative orders, as well as the proper procedure for seeking and issuing such an order. Always consult with local counsel on matters of state law.

For additional information on the use of court orders and irrevocable criminal justice consent forms, see pages 36-40 of Confidentiality and Communication: A Guide to Federal Drug and Alcohol Confidentiality Law and HIPAA (Legal Action Center 2012).

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