TRS-2 Generic Part 2 Consent Form concerning substance use disorder patients. Multiple languages available.

CONSENT FOR RELEASE OF INFORMATION RREGARDING PERSONS WITH SUBSTANCE USE DISORDER REVOKED ON Staff Sig GIVE INSTRUCTIONS: A COPY OF THE FORM TO THE PATIENT! Prepare one (1) copy for the Patient's Case Record. If this form is used for billing purposes prepare an additional copy for the Resource and Reimbursement Agent.

1) I consent to the disclosure of confidential information to, and among, the New York State Office of Alcoholism and Substance Abuse Services NYS Justice Center for the Protection of People with Special Needs (JC) including its Vulnerable Persons Central Register (VPCR) for the purpose of investigating or making

For help with OASAS Applications: OASAS staff call (844) 891-1786; other users call (518) 485-2379, fax (518) 473-1316, or email [email protected]

A client can sign the consent form at any time during their treatment episode with the knowledge that it allows consent of the data for the entire treatment episode, from admission through discharge and is valid for three years following the last date of service.

Clients should be offered the opportunity to sign the Authorization for Release of Behavioral Health Information Form (TRS-61) at the time of admission or, if admitted prior to October 1, 2014 and participating in an Opioid Treatment Program, at …

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.

I may be denied treatment and/or determined ineligible for the Impaired Driver Program if I do not sign a consent form. I have received a copy of this form, as recognized by my signature below.

GIVE A COPY OF THE FORM TO THE PATIENT! Prepare one (1) copy for the Patient's Case Record. If this form is used for billing purposes, prepare an additional copy for the Resource and Reimbursement Agent. If this form is sent to another agency with a request for information, prepare an additional copy for the Patient's Case Record.

2012年11月21日 · OASAS - New Health Program Consent (Form DCH-5055) Author: New York State Department of Health Subject: OASAS - New Health Program Consent \(Form DCH-5055\) Keywords: oasas, consent, form dch-5055, dch-5055 Created Date: 11/19/2012 10:30:22 AM