CN-530 ANCH (6/18)(cs) CINA THERAPEUTIC COURT - HIPAA RELEASE OF INFORMATION ORDER IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT ANCHORAGE In the Matter of: ) ) ) ) ) ) ) ) CASE NO(s). ) Minor(s) under 18 years of age. ) CINA THERAPEUTIC COURT - ) HIPAA RELEASE OF ) INFORMATION ORDER ) This matter is before the court for consideration of the limited release of specific substance use disorder and behavioral health treatment records. The court makes the following findings: 1. On , the CTC participant: was accepted into the CTC program. 2. As a condition of participation in the CTC program, the above-named participant must attend recommended substance use disorder treatment and any recommended behavioral health treatment, and the CTC Team must monitor the participant's progress in treatment. 3. The participant has voluntarily and knowingly signed HIPAA 1 and 42 C.F.R. Part 2 compliance releases with the Treatment Provider, and the CTC 4. The information necessary to monitor the participant's progress in treatment includes: Assessments; diagnoses; urinalysis (UA) and other testing results; treatment attendance; compliance with treatment; progress in treatment; and prognosis. This treatment information is the minimum necessary to carry out the purpose of the disclosures. 2 1 Health Insurance Portability and Accountability Act of 1996 (HIPAA), Pub. Law No. 104-191, 110 Stat. 1936 (1996). 2 See 45 C.F.R. 247 164.508 and 42 C.F.R. 247 2.13(a). American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 CN-530 ANCH (6/18)(cs) CINA THERAPEUTIC COURT - HIPAA RELEASE OF INFORMATION ORDER THEREFORE, IT IS ORDERED THAT: 1. The Treatment Provider, , shall provide to the members of the CTC Team in this matter (parties and counsel assigned to the case) the following information regarding the above-named CTC participant: Assessments; diagnoses; urinalysis (UA) and other testing results; treatment attendance; compliance with treatment; progress in treatment; and prognosis. 2. The Treatment Provider shall continue to provide treatment information until the CTC participant's successful completion of, or termination from, the CTC program, but in no event later than twelve months from the date of the issuance of this order. 3. The CTC Team in this matter shall not re-disclose the information provided to persons or entities other than counsel or parties to this CINA proceeding, except as may be provided by law. Date Superior Court Judge Type or Print Name I certify that on a copy of this document was emailed/hand-delivered to: AG PD OCS Tribe GAL OPA-AJR OPA-ASD OPA-CLS Clerk: American LegalNet, Inc. www.FormsWorkFlow.com