false
Catalog
Patient Communication Choices Authorization Form - ...
Patient Communication Choices Authorization Form - ...
Patient Communication Choices Authorization Form - HCCIntelligence™ Premier Resource - 2024
Back to course
Pdf Summary
This document is an authorization form that allows a healthcare organization to share a patient's health information with designated family and friends involved in the patient's care or payment for care. The form includes spaces for the patient to list the names, relationships, and contact information of the authorized individuals. The patient can also indicate whether they authorize the organization to leave voicemail messages for these individuals.<br /><br />The form mentions several types of health information that may be shared, including HIV/AIDS, mental health, developmental disabilities, genetic testing, and substance use disorder treatment. If the patient is a minor, information about sexually transmitted illnesses, pregnancy, and birth control may also be disclosed.<br /><br />The patient is informed that they have the right to withdraw their authorization at any time, although any information already released before the withdrawal will not be affected. The document provides contact information to learn how to withdraw the authorization.<br /><br />The form also includes additional notices required by law. It states that once the authorized family member or friend receives the health information, it may no longer be protected by federal privacy laws. However, certain types of information, such as AIDS/HIV, genetic testing, mental health, and developmental disabilities, have stricter restrictions on further disclosure under Illinois law. Additionally, federal rules prohibit further disclosure of drug and alcohol information without the explicit consent of the person to whom it pertains.<br /><br />The patient is made aware that completing this authorization form is not mandatory, and they will still receive care from the organization even if they choose not to complete it. The form also informs the patient of their right to inspect and copy the mental health and developmental disabilities records to be released.<br /><br />The document is developed by the Home Centered Care Institute. Witness signatures and dates are provided for the patient, parent/guardian/legal representative, and the person who developed the document.
Keywords
authorization form
healthcare organization
patient's health information
family and friends
HIV/AIDS
mental health
genetic testing
withdraw authorization
federal privacy laws
Home Centered Care Institute
©2022 Home Centered Care Institute. All rights reserved.
×
Please select your language
1
English