FORM B – CONSENT FOR RELEASE OF PART 2 PROGRAM (SUD PROVIDER) INFO

FORM B – CONSENT FOR RELEASE OF PART 2 PROGRAM (SUBSTANCE USE DISORDER PROVIDER) INFORMATION
A Part 2 Program is a federally assisted: (i) individual or entity other than a general medical facility who holds itself out as providing, and provides, substance use disorder (SUD) diagnosis, treatment, or referral for treatment; (ii) an identified unit within a general medical facility that holds itself out as providing, and provides, SUD diagnosis, treatment, or referral for treatment; or, (iii) medical personnel or staff in a general medical facility whose primary function is provision of SUD diagnosis, treatment, or referral for treatment, and who are identified as such providers.
Section I

This section describes the individual whose information will be released
First Name *
First name of individual whose information will be released
M.I.
Middle initial of individual whose information will be released
Last Name *
Last name of individual whose information will be released
Date of Birth *

Month Day Year
Date of Birth of individual whose information will be released
Social Security Number
Social Security Number of individual whose information will be released
Address

Address of individual whose information will be released

Street Address Line 2

City State

Zip Code
I hereby authorize the disclosure of health information about the above individual as follows.
Section II

This section describes the entity that will release the information
Disclosing Entity (Name of Holder of Part 2 Program Information) *
Name of the organization that will disclose the information
Telephone Number
Telephone number of the organization that will disclose the information
Address

Disclosing Entity Address

Street Address Line 2

Disclosing Entity City Disclosing Entity State

Disclosing Entity Zip Code
The information is to be provided to the following: *
namedIndividualX
namedPayerX
namedTreatmentProviderX
namedNonTreatmentProviderX
Name of Individual: *
Enter the name of the Named Individual who will receive the information
Name of Third Party Payer *
Enter the name of the Third Party Payer who will receive the information
Name of Treatment Provider Entity *
Enter the name of the Treatment Provider Agency who will receive the information
a. Named Individual Participant(s): *
Enter the name of the Named Individual Participant(s) who will receive the information
b. Named Treatment Provider Entity Participant(s): *
Enter the name of the Named Treatment Provider Entity Participant(s) who will receive the information
c. Description of Group or Class of Treatment Provider Entity Participant(s): *
Contact Information e.g. telephone number, email address, fax number, street address, etc
Enter contact information for the disclosure recipient in the box above. The agency that will disclose the information will use this information to contact the recipient.
Section III

This section describes disclosure reasons, information to be disclosed, and the period of time from which information should be released
Reason for Disclosure *

Guest Dosing Transfer Continuity of Care Legal Matters Other Reason (specify below)
Health information to be disclosed *

Dosing (Last 90 Days) Toxicology Results (Last 90 Days) Lab Testing Biopsychosocial Assessments Medical Progress Notes Demographics Other Information (specify below)
Specify time period, if desired:
Release only information from the period Date to Date
Section IV

This section describes the date through which this release will be active and it collects signatures of the individual whose information will be disclosed, or a representative of that individual
This authorization will remain in effect until revoked or shall expire on date or event specified below. I understand that I may revoke or cancel this authorization at any time by submitting written revocation in the manner specified by the disclosing entity, except to the extent that action has been taken in reliance on this authorization. If this authorization has not been revoked, it will expire on the date or completion of the event stated below. If no date or event is specified below, this authorization will expire in one year.
Expiration Date (Optional)

Month Day Year
Expiration Date of Release
Expiration Event (Optional)

Guest Dosing Ends / Return to Clinic Discharge from CompDrug Other Event (specify below)
- Substance use disorder records of Part 2 programs disclosed pursuant to this Consent are protected by federal regulations and cannot be re-disclosed without my written consent unless otherwise provided for in the regulations. Any information disclosed pursuant to this Consent other than substance use disorder records or records protected under another state law may be subject to re-disclosure by the recipient.
- I might be denied services if I refuse to authorize disclosure of information for purposes of assessment, treatment, or payment relating to substance use disorder if refusal is permitted by state law. My refusal to authorize disclosure of information for other purposes will not affect my ability to obtain treatment or services.
- If I have authorized disclosure to a generally described group or class of participants in an entity which is not my treatment provider, upon my written request, I must be provided a list of entities to which my information has been disclosed pursuant to that general designation.
Who authorizes this release? *

The individual whose information will be released A representative of the individual whose information will be released
Signature of Individual *

Clear
Signature Date *

Month Day Year
Name of Individual *

Signing Individual First Name Signing Individual Last Name
Signature of Personal Representative *

Clear
Signature Date (Personal Representative) *

Month Day Year
Name of Personal Representative *

Personal Representative First Name Personal Representative Last Name
Relationship of Personal Representative *

Parent Legal Guardian Healthcare Power of Attorney Executor/Adminstrator Other N/A
Method of Delivery (e.g. paper, fax, electronic)

Paper Electronic Fax Other Method (specify below)
Date Released

Month Day Year
Date
Calculation
Calculation
Calculation
Calculation
Calculation
CompDrug may need to contact you to confirm information on this request. Below, you have the option to provide approval and a phone number for CompDrug to reach out to you for any clarifications before releasing your information.

This option is provided for your convenience so that your request can be completed as quickly as possible.

If you do not authorize a specific phone number, your request may be delayed. CompDrug will attempt to contact you based on existing information on record.
I authorize CompDrug to contact me with any questions about my Release of Information request *
If you select No, CompDrug will still attempt to reach you using existing contact information on record if items on this form require clarification. This may delay the release of your information.
Phone Number *
Please enter a valid phone number for CompDrug to contact you with any questions about your request
CompDrug Release ID (for reference only)
Should be Empty:

FORM B – CONSENT FOR RELEASE OF PART 2 PROGRAM (SUBSTANCE USE DISORDER PROVIDER) INFORMATION

Section I

Section II

Section III

Section IV