THE INDIGENT CARE COLLABORATION
The Indigent Care Collaboration (“ICC”) is composed of various independent Texas healthcare organizations that provide health care services to individuals residing in the Travis, Hays, and Williamson Counties regardless of an individual’s ability to pay. The ICC Members are listed in an attachment to this Form. The number and identity of ICC Members may change from time to time. To better coordinate health care provided to uninsured individuals, to overcome barriers to health care access faced by uninsured individuals, and to implement appropriate disease management systems to improve the health status of uninsured individuals, the ICC Members may need to use and share confidential health information of uninsured individuals among themselves. This use and disclosure will require an authorization by each uninsured or underinsured individual (or individual’s representative) who desires to participate. If you agree to authorize the use and disclosure of your confidential health information among ICC Members, as set forth in this Form, please sign below.
I _________________________ authorize employees of ICC Members and health care providers affiliated with ICC Members to use, release and disclose my confidential health care information for the purposes set forth above, to other ICC Members, their employees, and health care providers affiliated with ICC Members.
I understand that “confidential health information” includes diagnoses, diagnostic tests and lab results, and drugs that have been prescribed for me and includes contact information (name, social security number, address, phone number, etc.) and demographic information (gender, race, age, etc.) that is housed in any of the medical records of all the ICC Members.
I understand that information released may include mental health, substance abuse (e.g., drugs, alcohol) and/or HIV/AIDS status, diagnostic and treatment records. IF I DO NOT WANT THIS INFORMATION DISCLOSED, MY OPTION IS NOT TO SIGN THIS AUTHORIZATION. If I sign this Authorization, such information will be received, used and disclosed by ICC Member organizations as authorized by state and federal law.
I understand that this is a limited Authorization. I am only authorizing the release of confidential health information that includes diagnoses, diagnostic tests and lab results, drugs that have been prescribed for me; contact information (name, social security number, address, phone number, etc.) and demographic information (gender, race, age, etc.) that is housed in any of the medical records of all the ICC Members.
Pursuant to legal agreements between each ICC Member and the ICC, your confidential health information is stored in a centralized health care database operated by the ICC. By signing this Authorization, the ICC will be allowed to make your confidential health information available through the internet, but only to ICC Members, employees of ICC Members, and to health care providers affiliated with members of the ICC for continuity of care, disease management, and health care operations, including quality assessment and improvement and program evaluation.
I fully intend this authorization to cover all ICC Members irrespective of which ICC Member requests that I complete this Authorization. Furthermore, I expressly intend that all ICC Members rely on this Authorization, unless and until it is revoked and ICC Members have had a reasonable period of time in which to act on my revocation.
I understand that once I sign this Authorization it may take approximately two (2) weeks for my medical information to be available to ICC Members and to health care providers affiliated with ICC Members.
I understand that I have a right to revoke this Authorization at any time. Revocation must be in writing and mailed or hand delivered to:
Indigent Care Collaboration
c/o Application Administrator
1213 N. IH-35
Austin, Texas 78702
The form attached to this Authorization may be used to revoke this Authorization. I understand that if I submit a revocation, there may be a delay between the time the revocation is received by the ICC and the time that my information is removed from further disclosure, but that this delay will generally not exceed seventy two (72) hours.
I understand that any disclosure of information carries with it the potential for redisclosure by the recipient and the information may not be protected by the federal privacy regulations.
I understand that this Authorization supercedes and revokes all authorizations signed by me at other ICC member organizations for the same purpose, use and disclosure of confidential health information by ICC Members.
I understand that I may review and receive a copy of the confidential health information released pursuant to this Authorization if I request it. I further understand that I may be required to pay a fee for copies of this information.
A signed copy of this Authorization will be provided to me, upon request.
I understand that I may refuse to sign this Authorization and that my refusal will neither affect my ability to obtain treatment from any ICC Member, nor my eligibility for benefits.
I understand this Authorization expires two (2) years from the date I sign this Authorization, unless otherwise revoked by me in writing prior to that time.
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Name of Individual Signature of Individual or Authorized Party Date
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(If different from individual) Relationship of Authorized Party to Individual
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Witness Date