Have you ever been tested for HIV infection? Do you know the results of the test
(If female) Have you given birth to an HlV-infected infant?
Are you sexually active?
Do you engage in anal intercourse (voluntary or forced)?
Do you engage in oral sex?
(If male) Do you have sex with other men? (Men should be asked specifically whether they have ever had
sex with other men, not whether they are "homosexual" or "gay," because they may not identify with the
use of these terms.)
Did you use condoms the last time you had sex? (Ask this to determine consistency of condom use, rather
than asking, "Do you use condoms?")
How many sexual partners have you had in the last 6 months? (Ask about the number of sexual partners
over a specific period of time, such as 6 months. Questions such as "How many sexual partners do you
have?" may elicit the answer, "one," despite a history of serial monogamy.)
Do you know about your partner's risk history (his or her drug use, sexual partners, blood transfusions,
etc.)?
Have you ever traded sex for something (money, drugs, shelter, etc.)?
Have you ever been forced to have sexual activity against your will?
Have you ever injected drugs?
Have you ever shared drug-injecting paraphernalia?
Have you ever had a transfusion of blood or blood products?
Have you ever had any other sexually transmitted diseases, including:
- Human papillomavirus?
- Herpes simplex virus?
- Hepatitis B and C?
- Gonorrhea?
- Chlamydia?
- Syphilis?
- Chancroid?
- Lymphogranuloma veneretims?
Exhibit 6-1
Consent for the Release of Confidential Information: Criminal Justice System Referral
I,
Name of defendant)
hereby consent to communication between
Treatment program)
and
Court, probation, parole, and/or other referring agency)
the following information:
Nature of the information, as limited as possible)
The purpose of and need for the disclosure is to inform the criminal justice agenc(ies) listed above of my attendance and progress in treatment. The extent of information to be disclosed is my diagnosis, information about my attendance or lack of attendance at treatment sessions, my cooperation with the treatment program, prognosis, and I understand that this consent will remain in effect and cannot be revoked by me until:
_____There has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment, or
Other time when consent can be revoked and/or expires)
I also understand that any disclosure made is bound by Part 2 of Title 42 of the Code of Federal Regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records and that recipients of this information may redisclose it only in connection with their official duties. Date(Signature of defendant/patient) Signature of parent, guardian, or authorized representative if required)
Exhibit 6-2
Consent for the Release of Confidential Information
I,
Name of patient)authorize
(Name or general designation of program making disclosure)
to disclose to
(Name of person or organization to which disclosure is to be made)
the following information:
Nature of the information, as limited as possible) The purpose of the disclosure authorized herein is to:
(Purpose of disclosure, as specific as possible) I understand that my records are protected under the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically as follows: (Specification of the date, event, or condition upon which this consent expires)
Dated:
Signature of participant)
Signature of parent, guardian, or authorized representative when required
Exhibit 6-3
Prohibition on Redisclosing Information Concerning AOD Abuse Treatment Patients
This notice accompanies a disclosure of information concerning a client in alcohol/drug abuse treatment, made to you with the consent of such client. This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
Exhibit 6-4
Qualified Service Organization Agreement
XYZ Service Center ("the Center") and the
(Name of the program)
("the Program") hereby enter into a qualified service organization agreement, whereby the Center agrees to provide the following services:
(Nature of services to be provided) Furthermore, the Center:
Acknowledges that in receiving, storing, processing, or otherwise dealing with any information from the Program about the patients in the Program, it is fully bound by the provisions of the Federal Regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2; and
Undertakes to resist in judicial proceedings any effort to obtain access to information pertaining to patients otherwise than as expressly provided for in the Federal confidentiality regulations, 42 CFR Part 2.
Executed this _____ day of __________, 199__.
__________________________
President
XYZ Service Center
(Address)
___________________________
Program Director
(Name of Program)
(Address)
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