Resource Center: Rules, regulations and recordkeeping, Consent

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Sample Consent Form

Description: 
This is a sample of a consent form that can be used when initiating buprenorphine treatment for a new patient.

BUPRENORPHINE MAINTENANCE TREATMENT

Sample #1 --Patient information and consent to treatment with buprenorphine

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Pharmacy Consent Form for Buprenorphine Treatment

Description: 
By signing this Appointed Pharmacy Consent Form, the patient authorizes a physician to disclose to the pharmacy that he or she is being treated for opioid dependence; the pharmacy is also authorized to contact the physician to discuss treatment.

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California Society of Addiction Medicine (CSAM)
Description: 
The California Society of Addiction Medicine (CSAM) website provides information and materials for buprenorphine treatment providers, including screening tools and sample consent and patient agreement forms, and provides links to other helpful resources.
Source: 
California Society of Addiction Medicine (CSAM)
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Patient Handout: Confidentiality and Consent

Description: 
This is a patient handout to inform patients about their rights when undergoing office-based buprenorphine treatment.

Patient Rights: Confidentiality and Consent

As a patient getting treatment for a substance use disorder, your personal and medical

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Minors' Right to Consent to Health Care and to Make Other Important Decisions
Description: 
This series of tables provides state-by-state information about minors' rights regarding providing consent for substance abuse treatment.
Source: 
Guttmacher Institute
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Consent to Release Confidential Information

Description: 
Consent to Release Confidential Information

Consent to Release Confidential Information
I ___________________________________ hereby authorize and request,
Name: ______________________________________

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CONSENT FOR RELEASE OF INFORMATION
Description: 
CONSENT FOR RELEASE OF INFORMATION
Source: 
training.aaap.org
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Patient Rights: Confidentiality and Consent (en Español)

Description: 
This patient handout explains how consent and confidentiality are respected as a part of drug treatment.

Derechos de los pacientes: confidencialidad y consentimiento

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Sample Confidentiality and Consent Forms
Description: 
This appendix from TAP 13: Confidentiality of Patient Records for Alcohol and Other Drug Treatment provides sample consent forms for substance abuse patients.
Source: 
Substance Abuse and Mental Health Services Administration (SAMHSA)
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Know Your Rights
Description: 
Guidance on the legal rights of individuals with alcohol and drug problems to help patients understand how they are protected from discrimination.
Source: 
The National Alliance of Advocates for Buprenorphine Treatment (NAABT)
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