Below are sample forms and materials for substance use disorder treatment programs. These forms comply with HIPAA and the recent amendments to 42 C.F.R. Part 2. Please continue to check this page for new, updated sample forms and materials, and subscribe here to receive information about new resources, including the forthcoming edition of LAC’s seminal book, Confidentiality and Communication.

  • 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.

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