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  • Consent for the Release of Information under 42 C.F.R. Part 2
    Confidentiality of Substance Use Disorder Patient Records

  • Patient Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Information to be Disclosed

    I understand the information to be released or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), mental health and substance use. I authorize the release or disclose of the records below.

  • Select Records to be Released*
  • Only the following specific types of records (check each that apply)*
  • Date of Information to be Disclosed*
  • Start Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • End Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Purpose of Disclosure (select all that apply)*

  • By signing this document, I understand that my substance use disorder patient records are protected under federalregulations 42 C.F.R. Part 2 Confidentiality of Substance Use Disorder Patient Records and cannot be disclosedwithout my written consent. I do not need to sign this form to obtain treatment. This consent will terminate in one year from the date of signature or 90 days after discharge, whichever comes first.

  • I understand that generally BrightView may not condition my treatment on whether I sign a consent form, but incertain limited circumstances, I may be denied treatment if I do not sign a consent form. I may revoke this consent atany time in person, by email, or verbally by calling BrightView, but I understand that the revocation will not be effectiveretroactively for disclosures that have already occurred.

  • Today's Date*
     / /
    2 digit month, 2 digit day, 4 digit year

  • If applicable, SIGNATURE OF PERSONAL REPRESENTATIVE; required only if patient is under a legal guardianship

  • Today's Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • Notice of Federal Requirements Regarding the Confidentiality of Substance Use Disorder Patient Information

    The confidentiality of substance use disorder patient records maintained by this program is protected by federal law and regulations. Generally, the program may not say to a person outside the program that a patient attends the program, or disclose any information identifying a patient as someone receiving substance use disorder treatment unless:

    1. The patient consents in writing; or
    2. The disclosure is allowed by a court order accompanied by a subpoena; or
    3. The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation; or
    4. The patient commits or threatens to commit a crime either at the program or against any person who works for the program.

    Violation of federal law and regulations by a program is a crime. Suspected violations may be reported to the  United States Attorney in the district where the violation occurs.

    Federal law and regulations do not protect any information about suspected child abuse or neglect from  being reported under state law to appropriate state or local authorities.

    The releases of information will remain active and valid for one year from the date of signature OR until 90 days after discharge (whichever comes first). There are several ways to revoke a release of information: Come into the BrightView facility where you were scheduled to receive treatment and sign the revocation, or call BrightView call center at 833-510-HELP (4357).

     

    (See U.S.C. §290dd-2 for federal law and 42 C.F.R. Part 2 for federal regulations governing Confidentiality of  Substance Use Disorder Patient Records.)

     

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