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The Tuberculosis Epidemic: Legal and Ethical Issues for Alcohol and Other Drug Treatment Providers
Treatment Improvement Protocol (TIP) Series 18

Appendix C -- Sample Forms

Sample Form No. 1: Consent for the Release of Confidential Alcohol or Drug Treatment Information

I, __________________________________________________________________, authorize

(Name of patient)
________________________________________________________________________________________
(Name or general designation of program making disclosure)
to disclose to _____________________________________________________________________ the
(Name of person or organization to which disclosure is to be made)
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

Sample Form No. 2: Prohibition on Redisclosure of Information Concerning Client In Alcohol or Drug Abuse Treatment

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.

Sample Form No. 3: Consent for the Release of Confidential Alcohol or Drug Treatment and [TB] [STD] [HIV/AIDS] Information To Comply With Disease Reporting Requirements

I, ________________________________________________________________ authorize

(Name of Patient)
The ABC Substance Abuse Program
___________________________________________________________________________ to disclose to
(Name of general designation of program making disclosure)
the [State and/or local] Department of Health officials authorized to require and receive mandated [HIV/AIDS/STD/TB] reports
__________________________________________________________________________________________
(Name of person or organization to which disclosure is to be made)
the following information: (Nature of the information as limited as possible)
(1) information that State law requires to be reported about my diagnosis and treatment for -- [initial any which apply]
___________ HIV infection
___________ AIDS
___________ STD (sexually transmitted disease)
___________ TB (tuberculosis)
(2) my name and other personal identifying information, if required to be reported by State law; and
(3) information about my status as a patient in alcohol or drug treatment, if required to be reported by State law.
The purpose of the disclosure authorized herein is to:
allow my alcohol or drug treatment program (named above) to comply with State law(s) requiring the reporting of cases of [HIV/AIDS/STD/TB].
___________________________________________________________________________________________
(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 C.F.R. Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that HIV-related information about me, STD-related information about me, and TB-related information about me is protected by State law and cannot be disclosed unless the disclosure is authorized by State law. 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 Patient

Sample Form No. 4: Consent for the Release of Confidential Information About Alcohol or Drug treatment and [TB] [STD] [and/or] [HIV/AIDS] Care

I, [name and address of patient], authorize --

the following alcohol or drug treatment program(s): [name and address of each treatment program authorized to make and receive disclosures], AND
the following health care provider(s): [name and address of each [TB][STD] {and/or][HIV/AIDS] care provider authorized to make and receive disclosures], AND
[designate staff of the State/local Department of Health responsible for [TB][STD] [and/or] [HIV/AIDS] prevention, control and care; specify appropriate name and address] --

to communicate with and disclose to one another the following information:
[initial each category that applies]*
*_____(1) Alcohol or drug treatment: Information about my participation and attendance in the alcohol or drug treatment program(s) named above that is needed to enable the persons and agencies listed above to provide, coordinate, and monitor my treatment for [TB] [STD] [and/or] [HIV/AIDS].
*_____(2) Tuberculosis (TB): Information about my diagnosis and treatment for TB that is needed to enable the persons and agencies listed above to provide, coordinate, and monitor my treatment for [TB] [STD] [and/or] [HIV/AIDS].
*_____ (3) Sexually transmitted disease(s) (STD): Information about my diagnosis and treatment for any STD that is needed in order to enable the persons named above to provide, coordinate and monitor my treatment for the [TB] [STD] [and/or] [HIV/AIDS].
*_____ (4) HIV/AIDS: Information about my HIV status (including HIV test results and information about my diagnosis and treatment for HIV-related conditions, including AIDS) that is needed to enable the persons and agencies listed above to provide, coordinate, and monitor my treatment for [TB] [STD] [and/or] [HIV/AIDS].

The purpose of these disclosures is to (1) enable the persons and agencies listed above to provide, coordinate, and monitor the treatment I receive for [TB] [STD] [and/or] [HIV/AIDS]; and (2) discuss with me any [sexual/needle sharing] partners or contacts and/or family members who might be infected [with [TB] [STD] [HIV] and need treatment.

I understand that my alcohol and drug treatment 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 HIV-related information about me, STD-related information about me, and TB-related information about me is protected by State law, and cannot be disclosed except as authorized by State law.

I understand that I may revoke this consent at any time except to the extent that action has already been taken in reliance on it, and that in any event this consent expires automatically as follows:
[Specify the date, event, or condition upon which this consent expires.
This could be one of the following:
(1) The date on which my treatment for [TB] [the STD] is completed.
(2) A specific date (such as 6 months or 1 year) after the consent form is signed.]
Dated:
Signature of patient

Sample Form No. 5: Qualified Service Organization Agreement on Coordination of [HIV/STD/TB] Care (AOD Treatment Program and [HIV/STD/TB] Health Care Provider)

[Name of health care facility providing [HIV/AIDS/STD/TB] care to Program patients] ("the [HIV/AIDS/STD/TB] Care Provider") and the [name of alcohol or drug treatment program] ("the Program") hereby enter into a qualified service organization agreement, whereby the [HIV/AIDS/STD/TB] Care Provider agrees to [provide, coordinate, and/or monitor] the treatment and/or related services for [HIV/AIDS/STD/TB] being provided to patients of the Program who are diagnosed, treated, and/or provided related services for [HIV/AIDS/STD/TB] by the [HIV/AIDS/STD/TB] Care Provider.

Furthermore, the [HIV/AIDS/STD/TB] Care Provider:
(1) 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 C.F.R. Part 2; and
(2) 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 C.F.R. Part 2.

Executed this _____ day of _____________________, 199___.
President
[Name of [HIV/AIDS/STD/TB Care Provider]
[address]
AOD Program Director
[Name of Program]
[address]

Sample Form No. 6: Qualified Service Organization Agreement on Reporting of [HIV/AIDS/STD/TB] and Coordination of [HIV/AIDS/STD/TB] Care (AOD Treatment Program and Health Department [HIV/STD/TB] Staff)

_____________________________________________________________________
[Name of relevant Health Department [HIV/AIDS/STD/TB] unit and staff]
("the Health Department [HIV/AIDS/STD/TB] Unit") and the

_____________________________________________________________________
[name of alcohol or drug treatment program] ("the Program")
hereby enter into a qualified service organization agreement, whereby the Health Department [HIV/AIDS/STD/TB] Unit agrees to [provide, coordinate, and/or monitor] the treatment and/or related services for [HIV/AIDS/STD/TB] being provided to patients of the Program who are diagnosed and reported as having [HIV/AIDS/STD/TB] and are provided [HIV/AIDS/STD/TB]-related services by the Health Department [HIV/AIDS/STD/TB] Unit.

Furthermore, the Health Department [HIV/AIDS/STD/TB] Unit:

(1) 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 C.F.R. Part 2; and
(2) 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 C.F.R. Part 2.

Executed this _____ day of _____________________, 199___.
President
[Name of [HIV/AIDS/STD/TB Care Provider]
[address]
AOD Program Director
[Name of Program]
[address]

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The Tuberculosis Epidemic: Legal and Ethical Issues for Alcohol and Other Drug Treatment Providers Treatment Improvement Protocol (TIP) Series 18