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NEW SEASON
CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION
Patient ID:
Date:
Form 52 - Revised April 2020 Page 1 of 2
The Nexus article for this form can be found by clicking here.
I, , ,
Name of Patient Date of Birth
authorize
Name or general designation of organization/person making/requesting disclosure.
to disclose to/receive from:
Name of organization and/or person to/from which disclosure is to be made/requested.
the following information: ,
Nature of the information, as limited as possible.
including:
❒Intake Paperwork
❒Discharge/Transfer Summary
❒Billing Records
❒Psychosocial Evaluation or Assessment
❒Toxicology/Drug Test Results
❒MAR (Medication Administration Record)
❒History & Physical
❒Prescription Verification/COC
❒Treatment Plan/Review
❒Medical Test Results
❒Other:
The Purpose of the disclosure authorized herein is to:
Purpose of disclosure, as specific as possible.
I understand that my alcohol and/or drug treatment records are protected under the Federal
regulations governing Confidentiality and Drug Abuse Patient Records, 42 C.F.R., Part 2, and the
Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. pts 160 & 164,
and cannot be disclosed without my written consent unless otherwise provided for by 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:
Specific date, event, or condition upon which this consent expires; cannot be longer than 12 months
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 INFORMATION IN THIS RECORD
THAT IDENTIFIES A PATIENT AS HAVING OR HAVING HAD A SUBSTANCE USE DISORDER
EITHER DIRECTLY, BY REFERENCE TO PUBLICLY AVAILABLE INFORMATION, OR
THROUGH VERIFICATION OF SUCH IDENTIFICATION BY ANOTHER PERSON UNLESS
FURTHER DISCLOSURE IS EXPRESSLY PERMITTED BY THE WRITTEN CONSENT OF THE
NEW SEASON
CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION
Patient ID:
Date:
Form 52 - Revised April 2020 Page 2 of 2
INDIVIDUAL WHOSE INFORMATION IS BEING DISCLOSED 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 (SEE SEC.
2.31). THE FEDERAL RULES RESTRICT ANY USE OF THE INFORMATION TO INVESTIGATE
OR PROSECUTE WITH REGARD TO A CRIME ANY PATIENT WITH A SUBSTANCE USE
DISORDER, EXCEPT AS PROVIDED AT SEC. 2.12(C)(5) AND 2.65.
I was offered a copy of the release of information and at this time a copy.
__________________________________
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Completed 1 November 2021

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