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CONSENT FOR THE RELEASE OF CONFIDENTIAL ALCOHOL OR DRUG TREATMENT INFORMATION Mobile App

The simple “Consent For The Release Of Confidential Alcohol Or Drug Treatment Information” app offers an efficient process of signing, collecting and electronically archiving the patients' consent forms. Patients can sign within the app on the electronic device. Like paper forms, the patient confidentiality is maintained like any other health records. Medical personnel is able to support the patients without any extensive training. Alcohol and/or drug treatment records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 Code of Federal Regulations (CFR) Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 CFR, Parts 160 and 164, and cannot be disclosed without written consent unless otherwise provided for in the regulations. The form is HIPAA compliant and can be used by any health care provider.

  • Lendlease
  • The Cooperative
  • PG&E
  • oxy
  • Red Bull
  • Mirvac

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Take a peek inside the CONSENT FOR THE RELEASE OF CONFIDENTIAL ALCOHOL OR DRUG TREATMENT INFORMATION Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

  • {{data.title}}

Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico statictext

    I,

  • Ico textbox

    (NAME OF PATIENT)

  • Ico date

    (BIRTHDATE)

  • Ico statictext

    authorize

  • Ico textbox

    (NAME OR GENERAL DESIGNATION OF ALCOHOL/DRUG PROGRAM MAKING DISCLOSURE)

  • Ico statictext

    to disclose to:

  • Ico textbox

    (NAME OF PERSON OR ORGANIZATION TO WHICH DISCLOSURE IS TO BE MADE)

  • Ico statictext

    the following information:

  • Ico textbox

    (NATURE AND AMOUNT OF INFORMATION TO BE DISCLOSED, AS LIMITED AS POSSIBLE)

  • Ico statictext

    The purpose of the disclosure authorized herein is to:

  • Ico multiline

    (PURPOSE OF DISCLOSURE, AS SPECIFIC AS POSSIBLE)

  • Ico statictext

    consent unless otherwise provided for in the regulations.

  • Ico date

    (SPECIFICATION OF THE DATE, EVENT, OR CONDITION UPON WHICH THIS CONSENT EXPIRES)

  • Ico statictext

    I understand that generally the alcohol and/or drug treatment program may not condition my treatm...

  • Ico signature

    SIGNATURE OF PATIENT

  • Ico signature

    SIGNATURE OF PARENT, GUARDIAN OR AUTHORIZED REPRESENTATIVE (WHEN REQUIRED)

  • Ico date

    DATED:

  • Ico statictext

    Prohibition on Redisclosure of Confidential Information

  • Ico statictext

  • Ico statictext

    client in alcohol/drug treatment, made to you with the consent of such client.

  • ...and More!

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