Notice Of Confidentiality: Bernalillo, Sandoval & Valencia County - Southwest Family Guidance Center & Institute

Notice Of Confidentiality Of Alcohol And Drug Abuse Patient Records

FOR BERNALILLO, SANDOVAL & VALENCIA COUNTY ONLY. Intake forms are securely encrypted and HIPAA compliant.

Notice Of Confidentiality

ID #
CLIENT FIRST NAME*
CLIENT LAST NAME*
CLIENT DOB*
MM slash DD slash YYYY
Notice Of Confidentiality Of Alcohol And Drug Abuse Patient Records
EMAIL
The confidentiality of alcohol and drug abuse patient records maintained by this program is protected by Federal law and regulations. Generally, the program may not say to a person outside the program that a patient attends the program, or disclose any information identifying a patient as an alcohol or drug abuser 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 program evaluation.
Violation of the Federal law and regulations by a 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 program or against any person who works for the 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.

See 42 U.S.C. 290dd-3 and 42 U.S.C. 290ee-3 for Federal laws and 42 CFR part 2 for Federal regulations.
CONFIRMATION*
- I UNDERSTAND SWFGC WILL MAINTAIN A COPY OF THIS FORM TO CONFIRM YOUR RECEIPT OF THE NOTICE OF CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE PATIENT RECORDS.
DATE
MM slash DD slash YYYY

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Notice Of Confidentiality Of Alcohol And Drug Abuse Patient Records