Draft a vaild drug and alcohol Authorization

Drug and alcohol Authorization
Name
Institution

AUTHORIZATION FOR THE RELEASE OF THE DRUG AND ALCOHOL INFORMATION
The Patient’s Information Name:
___________________________________________________________________________
At this moment I am authorizing the provision and release of the drug and alcohol information. Therefore, the people concerned should provide the information that is pertaining to the medical is and the treatment. This information will be used for further assessments and treatment for further treatment. These treatments are needed about the medical care services as well as the treatment methods that are included in the information about the diseases that are communicable and are venereal diseases. The patients are also suffering from the mental health.
Released to: Obtained from:
____________________________________________ ____________________________________________
The Name of the designated Providerthe Name of designated Facility
____________________________________________ ____________________________________________
Preferred Address Preferred Address
____________________________________________ ____________________________________________
City, State,
Number Zip
Code
Phone Number
City, State
Number Zip
Code
Phone Number
Personal information that is supposed to be released:
___ Any available medical records
___ Alcohol and drug test records
___ Specific information: _____________________________________________________________
The purpose for needing this information:
___ Physicians___ Medical Claims Processing___ Self___Attorney___Other______________________
I understand that if I am requesting records/information for release to a patient representative or me:
We understand that there are laws that do not allow the release of these records
In some situations, these records may allow the patients to request the release of their information
The records for drug and alcohol abuse treatment and test records: The information in this category are limited in terms of their access due to the protection from the laws of the Federal confidentiality acts (42 CFR Parts 2) (Winstanley ET AL, 2008).

These laws in the Federal government prohibit people from accessing the records in this category and or making the requests for the release unless there is the expression or a permitted authority. Those that want this information have to receive permission that has been authorized by the person who is in charge of otherwise given the permission by the 42 CFR Parts 2.

I have understood the above and authorize the release of my drug and alcohol record
(or give relationship)
_____
THE INFORMATION THAT ARE INCLUDED HERE ARE AUTHORIZED FOR THE RELEASE AND INCLUDES THE RECORDS THAT SHOWS THE EXISTENCE OF A COMMUNICABLE DISEASES OFR THE DISEASES THAT ARE NOT COMMUNICABLE.
___________________________________________________________ __________________ __________
SignatureDateTime
___________________________________________________________ _______________________________
Reason PatientRelationship to Patients

Reference
Winstanley, E. L., Steinwachs, D. M., Ensminger, M. E., Latkin, C. A., Stitzer, M. L., & Olsen, Y. (2008). The association of self-reported neighborhood disorganization and social capital with adolescent alcohol and drug use, dependence, and access to treatment. Drug and alcohol dependence, 92(1), 173-182.