AUTHORIZATION TO DISCLOSE HEALTH INFORMATION
NOTICE:
$ Federal law says that the Agency cannot share your Health Information without your permission except in certain situations. If you sign this form, you are giving Healthcare and Family Services permission to share your Health Information that Healthcare and Family Services has with the person you indicate below.
$ This Authorization is voluntary.
$ Right to Revoke: If you decide you do not want Healthcare and Family Services to share your Health Information any longer, sign the Revocation at the end of this form and give this form to Healthcare and Family Services. If Healthcare and Family Services has shared your Health Information for a research study, Healthcare and Family Services may continue to use or share your Health Information for that purpose only.
$ Payment, enrollment or eligibility for benefits for your health care will not be affected if you do not sign this Authorization, unless the disclosure is for eligibility or enrollment determinations, or for risk determinations.
$ Healthcare and Family Services cannot promise that the person you permit Healthcare and Family Services to share your Health Information with will not share your Health Information with someone else you may not want to have your Health Information.
$ You can keep a copy of this Authorization, and can contact the Healthcare and Family Services Privacy Officer to get a copy if you do not have one.

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