Confidentiality of Substance Use Disorder Patient Records

OMB 0945-0010

Latest Forms, Documents, and Supporting Material

Document Name
Justification Statement for Non-substantive Change - Part 2 Forms.pdf Justification for No Material/Nonsubstantive Change
Supplemental Document Part 2 Investigative Agency Report Form.pdf Supplementary Document
Supplemental Document Part2_Breach_Portal_Questions.pdf Supplementary Document
3_1_2024 Part 2 Supporting Statement FINAL.docx Supporting Statement A
Programs Receiving a Complaint
Attach consent form with each disclosure (paper records)
Attach consent form with each disclosure (electronic records)
Reports to the Secretary
Right to Request Restrictions
Accounting of Disclosures of Part 2 Records
Right to Discuss Patient Notice
Less than 500 Affected Individuals (investigating and documenting breach) -- affecting
Less than 500 Affected Individuals (investigating and documenting breach) -- affecting 10-499
500 or More Affected Individuals (investigating and documenting breach)
Notice to Secretary (notice for breaches affecting fewer than 500 individuals)
Notice to Secretary (notice for breaches affecting 500 or more individuals)
Media Notice - Breach
Individual Notice-Substitute Notice (individuals' voluntary burden to call toll-free number for information)
Individual Notice-Substitute Notice (staffing toll-free number)
Individual Breach Notice-Substitute Notice (posting or publishing)
Individual Breach Notice-Written and E-mail Notice (processing and sending)
Individual Breach Notice-Written and E-mail Notice (preparing and documenting)
Individual Breach Notice-Written and E-mail Notice (drafting)
Disclosures for Audit & Evaluation - Paper
Disclosures for Audit & Evaluation - Electronic
Disclosures for Research - Paper
Disclosures for Research - Electronic
Documenting Emergency Treatment Disclosures
PDMP Reporting
Obtaining Consent for TPO
Patient Notice - Providing to Patient
Breach Notification - Training
Training Program Development
Notice to Accompany Disclosure - Updating
Updating Consent Form
Obtaining Consent - Training
Requests for Restrictions - Training
Accounting of Disclosures - Training
Patient Notice - Updating
Patient Notice and Right to Discuss - Training
Complaint Procedures & Nonretaliation- Training