TRS-62 (7/15)
NEW YORK STATE
OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES
CONSENT TO RELEASE OF INFORMATION
CONCERNING
ALCOHOLISM/DRUG ABUSE PATIENT
LOCADTR ASSESSMENT
Revoked On: ___________ Staff Initials: __________
Patient's Last Name First M.I.
Case Number
Facility Unit
INSTRUCTIONS:
GIVE A COPY OF THIS FORM TO PATIENT! Prepare one (1) copy for the patient's case record. If
this form is to be sent to another agency with a request for information, prepare an additional copy for the
patient's case record.
PATIENT’S CONSENT TO DISCLOSE AND OBTAIN PERSONAL IDENTIFYING INFORMATION
EXTENT OF NATURE OF INFORMATION TO BE DISCLOSED OR OBTAINED:
All information necessary to complete a personalized Level of Care for Alcohol and Drug Treatment Referral “LOCADTR” assessment.
PURPOSE OR NATURE FOR DISCLOSURE/RELEASE AND NAME OF ORGANIZATIONS DISCLOSING AND OBTAINING
PERSONAL IDENTIFYING INFORMATION:
I consent to the disclosure of confidential information to, and between, the New York State Office of Alcoholism and Substance Abuse
Services (OASAS), the OASAS-Certified treatment facility identified above of my clinical treatment including information from the
OASAS Client Data System (CDS) and my Social Security Number.
I understand that the level of care determination assessment will only be shared with me and the OASAS treatment facility identified
above. Unless I have given written permission to share the information with other agencies, programs or payers.
I further understand that non-personal identifying information may be evaluated so that the effectiveness of the LOCADTR assessment
tool can be evaluated.
I, the undersigned, have read the above and authorize the New York State Office of Alcoholism and Substance Abuse Services and the
staff of the OASAS-certified treatment facility named above to disclose and obtain such information as herein specified.
I understand that this consent may be withdrawn by me in writing at any time except to the extent that action has been taken in reliance
upon it. This consent shall expire within six (6) months from its signing, unless a different time period, event or condition is specified
below, in which case such time period, event or condition shall apply. I also understand that any disclosure of any identifying
information is bound by Title 42 of the Code of Federal Regulations (C.F.R.) Part 2, governing the confidentiality of alcohol and drug
abuse patient records, as well as the Health Insurance Portability and Accountability Act of 1996 (HIPAA) 45 C.F.R. §§160 &164; and
that redisclosure of this additional information to a party other than those designated above is forbidden without additional written
authorization on my part.
Any information released through this form MUST be accompanied by the form Prohibition on
NOTE:
Redisclosure of Information Concerning Alcoholism / Drug Abuse Patient (TRS-1)
I understand that generally the program may not condition my treatment on whether I sign a consent form, but that in certain limited
circumstances I may be denied treatment if I do not sign a consent form. I have received a copy of this form.
(Signature of Patient) (Signature of Parent/Guardian)
(Print Name of Patient) (Print Name of Parent/Guardian)
(Date) (Date)
