The PHS regulation at 42 CFR 2.31 requires a special consent document to authorize the disclosure of ADAP records.
The consent document must contain:
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1.
The specific name or general designation of the program or person permitted to make
the disclosure;
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2.
The name or title of the individual or the name of the organization to which disclosure
is to be made;
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4.
The purpose of the disclosure;
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5.
How much and what kind of information is to be disclosed;
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6.
The signature of the patient and, when required for a patient who is a minor, the
signature of a person authorized to give consent under State law, or legal guardian
or other person authorized under State law to act on behalf of the patient, or if
the patient has been adjudged incompetent or is deceased, the signature of a person
authorized to sign in lieu of the patient (see GN 00502.023);
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7.
The date on which the authorized person signs the consent;
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8.
A statement that the consent is subject to revocation at any time except to the extent
that the program or person that is to make the disclosure has already acted, relying
on the consent. This includes the provision of treatment services relying on a valid
consent to disclose information to a third party payer; and
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9.
The date, event, or condition upon which the consent will expire if not revoked before;
this date, event, or condition must be set to ensure that the consent will last no
longer than reasonably necessary to serve the purpose for which it is given.
A consent document to disclose an ADAP record must meet the above PHS and SSA requirements
before we can disclose any information. If any of the required information is illegible,
missing, or incomplete, return the consent to the requester with an explanation of
why we cannot honor it. Inform the requester of the information we need in order to
process a request.
NOTE: If the patient has died, the executor or administrator of the estate, or if there
is none, the spouse or closest other relative of the deceased patient may sign the
consent. (See 42 CFR 2.15(b)(2))