Community Referral For Health Home Care Management Services (Page 4 of 6) in pdf

PERMISSION TO USE AND DISCLOSE CONFIDENTIAL INFORMATION

By signing this Consent Form, you permit people involved in your care to share your health information so that your doctors and other

providers can have a complete picture of your health and help you get better care. Your health records provide information about your

illnesses, injuries, medicines and/or test results. Your records may include sensitive information, such as information about HIV

status, mental health records, reproductive health records, drug and alcohol treatment, and genetic information.

If you permit disclosure, your health information will only be used to provide you with medical treatment and related health and social

services. This includes referral from one provider to another, consultation regarding care, provision of health care services, and

coordination of care among providers. Your health information may be re-disclosed only as permitted by state and federal laws and

regulations. These laws limit re-disclosure of information about your treatment at a substance abuse or mental health program, HIV

related information, genetic records, and records of sexually transmitted illnesses.

Your choice to give or deny consent to disclose your health information will not be the basis for denial of health services or health

insurance. You can withdraw your consent at any time by signing a Withdrawal of Consent Form and giving it to one of the providers

listed in Attachment A. But anyone who receives information while your consent is in effect may retain it. Even if you withdraw your

consent, they are not required to return your information or remove it from their records.

You are entitled to get a copy of this Consent Form after you sign it.

CONSENT TO DISCLOSURE OF HEALTH INFORMATION

The person whose information may be used or disclosed is:

Name: ___________________________________________________________.

Date of Birth: ______________________________________________________.

The information that may be disclosed includes all records of diagnosis and health care treatment and all education

records including, but not limited to: Mental health records, except that disclosure of psychotherapy notes is not

permitted; Substance abuse treatment records; HIV related information; Genetic information; Information about

sexually transmitted diseases; and Education records.

This information may be disclosed to the persons or organizations listed in Attachment A.

This information may be disclosed by any person or organization that holds a record described below, including

those listed in Attachment A.

Use and disclosure of this information is permitted only as necessary for the purposes of the provision of delivery of

health and social services, including outreach, service planning, referrals, care coordination, direct care, and

monitoring of the quality of service.

This permission expires on ____________ (date).

I understand that this permission may be revoked. I also understand that records disclosed before this permission is

revoked may not be retrieved. Any person or organization that relied on this permission may continue to use or

disclose health information as needed to complete treatment.

I am the person whose records will be used or disclosed, or that individual’s personal representative. (If personal

representative, please enter relationship ____________________.)

I give permission to use and disclose my records as described in this document.

__________________________________________________________________

Signature

Date

Community Referral For Health Home Care Management Services Page 4