Pharmacy Consent Form for Suboxone Treatment

    I, , do hereby:

    I understand that I may withdraw this consent at any time, either verbally or in writing except to the extent that action has been taken on reliance on it. This consent will last while I am being treated for opioid dependence by the provider specified above unless I withdraw my consent during treatment. This consent will expire 365 days after I complete my treatment, unless the provider specified above is otherwise notified by me.

    I understand that the records to be released may contain information pertaining to psychiatric treatment and/or treatment for alcohol and/or drug dependence. These records may also contain confidential information about communicable diseases including HIV (AIDS) or related illness. I understand that these records are protected by the Code of Federal Regulations Title 42 Part 2 (42 CFR Part 2) which prohibits the recipient of these records from making any further disclosures to third parties without the express written consent of the patient.

    I acknowledge that I have been notified of my rights pertaining to the confidentiality of my treatment information/records under 42 CFR Part 2, and I further acknowledge that I understand those rights.

    Confidentiality of Alcohol- and Drug-Dependence Patient Records
    The confidentiality of alcohol- and drug-dependence patient records maintained by this
    practice/program is protected by federal law and regulations. Generally, the practice/program may not say to a person outside the practice/program that a patient attends the practice/program, or disclose any information identifying a patient as being alcohol- or drug-dependent unless:
    1. The patient consents in writing;
    2. The disclosure is allowed by a court order; or
    3. The disclosure is made to medical personnel in a medical emergency or to qualified
    personnel for research, audit, or practice/program evaluation.

    Violation of the federal law and regulations by a practice/program is a crime. Suspected
    violations may be reported to appropriate authorities in accordance with federal regulations. Federal law and regulations do not protect any information about a crime committed by a patient either at the practice/program or against any person who works for the practice/program or about any threat to commit such a crime. Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities.