Confidentiality

Consent to Release Confidential Information

Description: 
Consent to Release Confidential Information

Consent to Release Confidential Information
I ___________________________________ hereby authorize and request,
Name: ______________________________________

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Patient Rights: Confidentiality and Consent

Description: 
This is a patient handout to inform patients about their rights when undergoing office-based buprenorphine treatment.

Patient Rights: Confidentiality and Consent

As a patient getting treatment for a substance use disorder, your personal and medical
information is protected under United States confidentiality law. This law states that your provider
is not allowed to tell anyone the reason you are being treated, without your permission. Providers
and treatment programs that provide addiction treatment are not even allowed to tell anyone
whether or not you are a patient.

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Commonly Used Forms: 

Sample Consent Form

Description: 
This is a sample of a consent form that can be used when initiating buprenorphine treatment for a new patient.

BUPRENORPHINE MAINTENANCE TREATMENT

Sample #1 --Patient information and consent to treatment with buprenorphine

Buprenorphine is an FDA approved medication for treatment of people with heroin or other opioid addiction. Buprenorphine can be used for detoxification or for maintenance therapy. Maintenance therapy can continue as long as medically necessary. There are other treatments for opiate addiction, including methadone, naltrexone, and some treatments without medications that include counseling, groups and meetings.

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Commonly Used Forms: 

Hablando con su médico (Talking to Your Doctor (en Español))

Description: 
This patient handout sheet discusses the importance of honesty from both the patient and the doctor when talking about drug use and treatment.

Sea honesto con su médico

Su médico quiere proveer el mejor tratamiento posible para usted con un plan de tratamiento
que satisface las necesidades y las circunstancias únicas a usted. Esto se puede lograr a
través de una relación basada en la honestidad y la comunicación buena. Procure decir a su
médico si usted:

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Derechos de los pacientes: confidencialidad y consentimiento (Patient Rights: Confidentiality and Consent (en Español))

Description: 
This patient handout explains how consent and confidentiality are respected as a part of drug treatment.

Como un paciente que recibe tratamiento por un desorden del consumo de drogas, su
información personal y médica es protegida bajo la ley de confidencialidad de los Estados
Unidos. Esta ley declara que su médico no puede decir a nadie la razón por su tratamiento sin
el permiso de usted. Los médicos y programas del tratamiento que proveen tratamiento para la
adicción ni siquiera pueden decir que usted es un paciente.

Consentimiento del paciente

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Patient Handouts: 
Description: 
The California Society of Addiction Medicine (CSAM) website provides information and materials for buprenorphine treatment providers, including screening tools and sample consent and patient agreement forms, and provides links to other helpful resources.
Source: 
California Society of Addiction Medicine (CSAM)
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Description: 
An example of the wording and structure necessary in a consent for release of information form.
Source: 
Substance Abuse and Mental Health Services Administration (SAMHSA)
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Commonly Used Forms: 
Physician stage in practice: 
Description: 
This website from the American Academy of Family Physicians provides information about HIPAA and how physicians can implement its guidelines in their practices.
Source: 
American Academy of Family Physicians (AAFP)
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Physician stage in practice: 
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