Form 032-02-0162-01-ENG "Interagency Consent to Release Confidential Information for Alcohol or Drug Patients" - Virginia

What Is Form 032-02-0162-01-ENG?

This is a legal form that was released by the Virginia Department of Social Services - a government authority operating within Virginia. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2009;
  • The latest edition provided by the Virginia Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 032-02-0162-01-ENG by clicking the link below or browse more documents and templates provided by the Virginia Department of Social Services.

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Download Form 032-02-0162-01-ENG "Interagency Consent to Release Confidential Information for Alcohol or Drug Patients" - Virginia

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INTERAGENCY CONSENT TO RELEASE CONFIDENTIAL INFORMATION FOR
ALCOHOL OR DRUG PATIENTS
I,
, of
( Name of Patient/client)
(Patient/client’s address)
authorize
( Name, title, and organization making disclosure)
To disclose to:
(name, title and organization to whom disclosure is being made)
The following information:
( Specific information to be disclosed)
For the following purpose(s):
(Reason for disclosure)
I understand that my records are protected under Federal and State confidentiality laws and regulations
and cannot be disclosed without my written consent unless otherwise provided for the laws and regulations. I
also understand that I may revoke ( or cancel) this consent at any time, except to the action has been taken in
reliance on it, and that in any event this consent automatically expires as described below:
( Date, event, or condition upon which this consent will expire)
I further acknowledge that the information to be released as fully explained to me and that this consent is
given of my own free will.
Executed this, the
Day of
,20
This consent
includes
Does not include information placed on my records after the above
date.
(Signature of patient/client)
( Signature of parent/guardian, where required)
( Signature of person authorized to sign in lieu of parent)
NOTE WHERE INFORMATION ACCOMPANIES THIS DISCLOSURE FORM: This information has been
disclosed to you from records protected by Federal Confidentiality of Alcohol or Drug Abuse Patient Records
rules ( 42 CFR part 2.) The Federal rules prohibit you from making any further disclosure of this information
unless further disclosure is expressly permitted by the written consent of the person to whom it pertains 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. The Federal rules restrict any use of the information to criminally
investigate or prosecute any alcohol or drug abuse patient.
032-02-0162-01-eng (11/09)
INTERAGENCY CONSENT TO RELEASE CONFIDENTIAL INFORMATION FOR
ALCOHOL OR DRUG PATIENTS
I,
, of
( Name of Patient/client)
(Patient/client’s address)
authorize
( Name, title, and organization making disclosure)
To disclose to:
(name, title and organization to whom disclosure is being made)
The following information:
( Specific information to be disclosed)
For the following purpose(s):
(Reason for disclosure)
I understand that my records are protected under Federal and State confidentiality laws and regulations
and cannot be disclosed without my written consent unless otherwise provided for the laws and regulations. I
also understand that I may revoke ( or cancel) this consent at any time, except to the action has been taken in
reliance on it, and that in any event this consent automatically expires as described below:
( Date, event, or condition upon which this consent will expire)
I further acknowledge that the information to be released as fully explained to me and that this consent is
given of my own free will.
Executed this, the
Day of
,20
This consent
includes
Does not include information placed on my records after the above
date.
(Signature of patient/client)
( Signature of parent/guardian, where required)
( Signature of person authorized to sign in lieu of parent)
NOTE WHERE INFORMATION ACCOMPANIES THIS DISCLOSURE FORM: This information has been
disclosed to you from records protected by Federal Confidentiality of Alcohol or Drug Abuse Patient Records
rules ( 42 CFR part 2.) The Federal rules prohibit you from making any further disclosure of this information
unless further disclosure is expressly permitted by the written consent of the person to whom it pertains 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. The Federal rules restrict any use of the information to criminally
investigate or prosecute any alcohol or drug abuse patient.
032-02-0162-01-eng (11/09)