[Code of Federal Regulations]
[Title 42, Volume 1, Parts 1 to 399]
[Revised as of October 1, 2000]
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) {time}  Request {time}  Authorize:
2. (name or general designation of program which is to make the 
disclosure)
_______________________________________________________________________
3. To disclose: (kind and amount of information to be disclosed)
_______________________________________________________________________
4. To: (name or title of the person or organization to which disclosure 
is to be made)
_______________________________________________________________________
5. For (purpose of the disclosure)
_______________________________________________________________________
6. Date (on which this consent is signed)
_______________________________________________________________________
7. Signature of patient
_______________________________________________________________________
8. Signature of parent or guardian (where required)
_______________________________________________________________________
9. Signature of person authorized to sign in lieu of the patient (where 
required)
_______________________________________________________________________
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)