I understand that Adirondack Health Institute (“AHI”), the New York Department of Health (“DOH”), and the Community Service Society of New York (“CSS”) and its partner programs promote their work through publications, the media, and appeals for support, including publications transmitted via the Internet and other electronic media. By signing this Authorization, I permit those AHI, DOH, and CSS employees to use and disclose the Protected Health Information specifically set forth below.
“Protected Health Information” (“PHI”) is defined under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), as amended by the Omnibus Rule. PHI includes information about an individual, including demographic information that may identify the individual, and information that relates to the individual’s past, present or future physical, mental health or condition or related health care services, or payment for health care services.
I hereby authorize the parties named above to release those portions of my PHI specifically set forth below and approved by me to the general public for educational, publicity and/or fundraising purposes. I understand that once my PHI is disclosed, this information can be re-disclosed by others and will not be protected by HIPAA.
I hereby authorize AHI, DOH, CSS and the CSS Partner Programs to use, disclose and release the following elements of my PHI: My name, any medical conditions I have disclosed in my story, and the insurance coverage issues that brought me to this program.
Δ
