Psychotherapy Notes & SUD Records Release Authorization
Specialized authorization for release of psychotherapy notes (45 CFR 164.508(a)(2)) and substance use disorder records (42 CFR Part 2) — heightened protections beyond standard HIPAA.
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AUTHORIZATION FOR DISCLOSURE OF PSYCHOTHERAPY NOTES AND/OR SUBSTANCE USE DISORDER PATIENT RECORDS This authorization satisfies the heightened requirements of: • 45 CFR § 164.508(a)(2) for psychotherapy notes • 42 CFR Part 2 for substance use disorder records ═══════════════════════════════════════════════════════════════════════ 1. PATIENT ═══════════════════════════════════════════════════════════════════════ Name: Jordan Alex Taylor Date of birth: June 12, 1985 Address: 482 Elm Street, Apt 3B, Portland, OR 97214 ═══════════════════════════════════════════════════════════════════════ 2. DISCLOSING PROGRAM (PART 2 PROGRAM OR PSYCHOTHERAPIST) ═══════════════════════════════════════════════════════════════════════ Name: Westside Behavioral Health & Recovery, PLLC Address: 777 SW Madison St, Portland, OR 97205 ═══════════════════════════════════════════════════════════════════════ 3. RECIPIENT ═══════════════════════════════════════════════════════════════════════ Name: Dr. Sandra Whitfield, PsyD (continuing therapist) Address: 450 NW 23rd Ave, Portland, OR 97210 ═══════════════════════════════════════════════════════════════════════ 4. CATEGORY AND CONTENT OF RECORDS AUTHORIZED ═══════════════════════════════════════════════════════════════════════ Category: Psychotherapy notes only Specific content: Treatment summary, diagnoses, treatment plan, progress notes (process notes excluded except as separately authorized below), discharge summary. Date range: 2024-01-01 to date of authorization. (Strike or modify any element you do NOT wish to authorize.) ═══════════════════════════════════════════════════════════════════════ 5. PURPOSE OF DISCLOSURE ═══════════════════════════════════════════════════════════════════════ Continuity of care: I am transitioning from group practice to a private therapist for ongoing individual psychotherapy. The receiving therapist needs my treatment history to provide appropriate continuing care. ═══════════════════════════════════════════════════════════════════════ 6. EXPIRATION ═══════════════════════════════════════════════════════════════════════ Type: Date certain Date: May 8, 2027 Or event: Completion of intake with new provider, or 1 year from signature, whichever is sooner. ═══════════════════════════════════════════════════════════════════════ 7. RIGHT TO REVOKE ═══════════════════════════════════════════════════════════════════════ I understand that I may revoke this authorization at any time by submitting a written revocation to the disclosing program at the address in Section 2. The revocation will not apply to disclosures already made in reliance on this authorization. Revocation should be sent by certified mail or hand-delivered for a verifiable record. ═══════════════════════════════════════════════════════════════════════ 8. PROHIBITION ON RE-DISCLOSURE (42 CFR § 2.32) ═══════════════════════════════════════════════════════════════════════ THE FOLLOWING NOTICE MUST ACCOMPANY ANY DISCLOSURE OF SUD RECORDS: "This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR Part 2). The federal rules prohibit you from making any further disclosure of information in this record that identifies a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except as provided at §§ 2.12(c)(5) and 2.65." For psychotherapy notes (45 CFR § 164.508(a)(2)): re-disclosure is not protected by HIPAA after disclosure to a non-covered entity. Heightened state-law protections may apply. ═══════════════════════════════════════════════════════════════════════ 9. TREATMENT, PAYMENT, ENROLLMENT, ELIGIBILITY NOT CONDITIONED ═══════════════════════════════════════════════════════════════════════ The disclosing program may not condition my treatment, payment, enrollment in a health plan, or eligibility for benefits on whether I sign this authorization, except as permitted by 42 CFR § 2.31(a)(7) (authorization required as a condition of an SUD-treatment-related research program in which I have agreed to participate). ═══════════════════════════════════════════════════════════════════════ 10. SIGNATURES ═══════════════════════════════════════════════════════════════════════ _____________________________________ May 11, 2026 Patient signature Date _____________________________________ May 11, 2026 Witness (if patient unable to sign or Date patient is a minor without sole consent authority — see state law) ═══════════════════════════════════════════════════════════════════════ COPY TO PATIENT — ORIGINAL TO PROGRAM RECORD ═══════════════════════════════════════════════════════════════════════
About this template
This authorization addresses the two categories of health records that receive the strongest federal confidentiality protection: psychotherapy notes under 45 CFR § 164.508(a)(2) and substance use disorder (SUD) treatment records under 42 CFR Part 2. Psychotherapy notes are defined narrowly: notes recorded by a mental health professional documenting or analyzing the contents of a counseling session, kept separate from the rest of the medical record. They do NOT include medication prescription and monitoring, counseling session start/stop times, the modalities and frequencies of treatment, results of clinical tests, summary of diagnosis, functional status, treatment plan, symptoms, prognosis, or progress to date. The narrow definition is important — most of what a therapist documents is in the regular medical record and disclosed under standard HIPAA authorization. Only the separately maintained "process notes" require this heightened authorization, which: (a) cannot be combined with any other authorization on the same form (one narrow research-related exception); (b) requires specific identification of the recipient and purpose; (c) is subject to a meaningful right to revoke. Substance use disorder treatment records have their own federal regime: 42 CFR Part 2, originally adopted in 1975 and most recently substantially revised in 2024 (89 Fed. Reg. 12472, Feb. 16, 2024) to align certain elements with HIPAA. Part 2 applies to "Part 2 programs" — federally assisted programs (which captures most substance use treatment programs since they typically receive Medicaid/Medicare funding or DEA registration) that hold themselves out as providing SUD diagnosis, treatment, or referral. Records protected by Part 2 may not be disclosed except with a specific, written, Part 2-compliant consent or under one of the regulatory exceptions (medical emergency, qualified service organization agreement, audit/evaluation, court order with good cause, scientific research with strict protocols). The Part 2 consent has nine required elements (42 CFR § 2.31): (1) name of the patient, (2) name of the disclosing program, (3) name of the recipient, (4) name(s) of the individual or entity to which disclosure is to be made, (5) purpose of the disclosure, (6) explicit description of how much and what kind of information is to be disclosed, (7) signature, (8) date, and (9) statement that the consent may be revoked. The authorization must also include a prohibition-on-redisclosure notice (42 CFR § 2.32) — this is the boilerplate notice in Section 8 of this form, which must accompany any actual disclosure of Part 2 records. The 2024 final rule made several changes: (a) a single consent can authorize disclosure to a single recipient for treatment, payment, and operations purposes (TPO) for as long as the patient does not revoke; (b) Part 2 programs that are HIPAA covered entities may use a HIPAA-compliant Notice of Privacy Practices for Part 2; (c) restrictions remain on use of Part 2 records in legal proceedings against the patient. Important nuances: (1) State law may be more protective and is not preempted; states like New York, California, Massachusetts, and others have stricter mental health and SUD privacy laws. (2) Court-ordered disclosures of Part 2 records are subject to the special "good cause" standard at 42 CFR §§ 2.61-2.67; a generic subpoena is not sufficient. (3) Disclosure for enforcement of criminal conduct of the patient is generally prohibited under 42 CFR § 2.12(d), with narrow exceptions. (4) The 2024 rule increased patient rights including a right to an accounting of disclosures and a right to file complaints with HHS. Use this form when (a) the records involved are psychotherapy notes (separate process notes from a mental health professional), (b) the records are from a Part 2 SUD treatment program, or (c) both. For routine mental health records that are NOT process notes, the standard HIPAA authorization is sufficient.
When to use it
- Releasing psychotherapy process notes from a mental health professional.
- Releasing records from a federally assisted SUD treatment program.
- Transferring care from one mental health or SUD provider to another.
- Authorizing disclosure to a court, attorney, or third party at the patient's request.
- Whenever standard HIPAA authorization would be insufficient for the records involved.
What to include
- Patient name, DOB, and address.
- Disclosing program identity and address.
- Recipient identity and address.
- Specific category — psychotherapy notes, SUD records, or both.
- Specific content authorized — not "all records" alone.
- Specific purpose.
- Specific expiration date or event.
- Right-to-revoke statement.
- 42 CFR § 2.32 prohibition-on-redisclosure notice.
- Treatment-not-conditioned statement.
- Patient signature with date.