a. Release of Records for Compliance and Performance Improvement Purposes:I authorize the release of medical records information, and I specifically authorize the release of information concerning treatment relating to HIV testing, AIDS or AIDS related condition, treatment of mental health or psychiatric condition(s), and/or treatment of alcoholism or drug abuse to insurance carriers or their associates, third-party payers or their representatives, the Social Security Administration or other authorized governmental agency, and/or review organizations as deemed necessary to establish or verify my benefits entitlement, or that of the patient named below, for LCOHPA or clinician claims for services rendered and to process payment claims and obtain reimbursement from such third-party payers for the health services provided. I also authorize my records, or the records of the patient named below, to be released to state, federal, or other surveyors for accreditation and/or regulatory licensing purposes and to others engaged in health care operations such as training, credentialing, quality improvement, legal compliance, contracting, and administration. I also authorize release of my medical record information, or that of the patient named below, as required or permitted by law. For example, cases of HIV, tuberculosis, viral meningitis, and other communicable diseases may require mandatory reporting to organizations such as health departments or the Centers for Disease Control and Prevention. The authorization provided in this section will expire five years after the date of discharge. I am aware that I can revoke, in writing, this authorization at any time except to the extent that action has been taken in reliance thereon.
b. Release of Medical Records for Treatment Purposes:I authorize the release of medical records information, and I specifically authorize the release of all information concerning treatment relating to HIV testing, AIDS or AIDS related conditions, and/or treatment of mental health or psychiatric condition(s), to other health care providers who utilize an electronic medical record system compatible with the LCOHPA records system only for the purposes of providing treatment to me, or the patient named below. The authorization provided in this section will expire five years after the date of discharge. I am aware that I can revoke, in writing, this authorization at any time except to the extent that action has been taken in reliance thereon. I understand that if I refuse or revoke this authorization LCOHPA will not deny any treatment to me or the patient named below.
c. Photography:I understand and agree that I, or the patient named below, will be photographed for purposes of identification, helping to assure safety, and assisting in certain health care operations of LCOHPA, such as performance improvement programs.
d. Electronic Prescribing:I hereby consent to and authorize LCOHPA and its affiliates, including physicians or other prescribers providing treatment to me or the patient named below at a LCOHPA facility, to access or input prescription benefit or medication history for me, or the patient named below, on the Surescripts Network or other electronic prescription services.
e. Medical Records Access and Retention:Medical records of LCOHPA are kept on file for the period of time designated in LCOHPA’s document retention policy and then destroyed. Subject to appropriate authorization or applicable law, I understand that every patient or his or her legal representative has a right to inspect and obtain a copy of his or her medical record. There will be a charge for this service.
f. Medical Research:I understand that Linder Center of HOPE is a research facility. As such, I grant the Lindner Center of HOPE research treatment team access to my records or those of the patient named below to determine if I or the patient named below may be eligible for a current or potential study. This consent involves only the review of records. Additional information and consents would be provided in the event that I or the patient named below is considered for a study.
g. Contact Information:I have voluntarily given my cell phone, home phone, and/or other contact number so that I may be contacted. I authorize LCOHPA or its agents to contact me at any telephone number associated with my account, including wireless telephone numbers or other numbers that may result in a charge to me, whether provided in the past, present, or future. I also authorize contacts and messages by automated dialers and other mechanical devices that may or may not leave messages regarding my account or that of the patient named below, such as for purposes of collection services and appointment reminders.