Exercise of Free Expression. DRUG-AND ALCOHOL- FREE CAMPUS. Career/technical certificates, degrees, and transfer programs. We cultivate. Example: John Smith with date of Birth = and student ID# 0123456. Certificate of Completion: Certificates for a course or a series of courses fewer than.

Below are sample forms and materials for substance use disorder treatment programs. These forms comply with HIPAA and the recent amendments to 42 C.F.R. Please continue to check this page for new, updated sample forms and materials, and here to receive information about new resources, including the forthcoming edition of LAC’s seminal book,.

Sample consent form for the release of a patient’s confidential substance use disorder information to any individual. Sample consent form for the release of a patient’s confidential substance use disorder information to an entity that has a treating provider relationship with the patient. Sample consent form for the release of a patient’s confidential substance use disorder information to a third-party payer. Sample consent form for the release of a patient’s confidential substance use disorder information to an entity that does not have a treating provider relationship with the patient.

• Sample Notice Prohibiting Redisclosure, to accompany a patient’s confidential alcohol or drug treatment records. A sample letter that alcohol or drug treatment programs may use to respond to a civil subpoena that does not comply with the requirements of the federal confidentiality law, 42 C.F.R. A sample letter that alcohol or drug treatment programs may use to respond to a criminal subpoena that does not comply with the requirements of the federal confidentiality law, 42 C.F.R. •. An example of a court order that would allow an alcohol or drug treatment program that is covered by both 42 C.F.R. Part 2 and HIPAA to use the irrevocable criminal justice consent form permitted under 42 C.F.R. § 2.35 for a particular patient.

Adapted from a court order drafted by the New York State Office of Court Administration. An example of a standing court order that would allow an alcohol or drug treatment program covered by both 42 C.F.R. And HIPAA to use the irrevocable criminal justice consent form permitted under 42 C.F.R. § 2.35 for all patients of that particular program. Adapted from a court order drafted by the New York State Office of Court Administration.

Important reminder: State laws and court rules may affect the content of court or administrative orders, as well as the proper procedure for seeking and issuing such an order. Always consult with local counsel on matters of state law.

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