Substance Abuse Treatment Information Release
Client Information
Name
Date of Birth
Client ID (if applicable)
Recipient of Information
Name/Organization
Address
Phone/Fax
Purpose of Disclosure
Information to be Released
Expiration
This authorization will expire on
I understand that my substance use records are protected under federal confidentiality regulations (42 CFR Part 2) and cannot be disclosed without my written consent unless otherwise permitted by law.
Client Signature
Date
Witness/Parent/Guardian (if required)
Date