Authorization Form Questions and
Answers
☻ What is the ICC?
The ICC is a nonprofit group of health care providers in the Austin area who are working together to give you and your neighbors better health care that will cost less. These health care providers are the ones who most likely give you most of your health care.
☻ The “ICC Authorization to Use and Disclose Confidential Information” is long, and hard to understand. What does it really say?
It says that you give your permission for ICC health care providers to share some of your health information with each other when you receive care. The only information they will share with each other is information about your medical condition, prescription drugs, medical tests, and diagnoses that came from a visit to any ICC member.
☻ Why does the ICC want me to sign this?
By sharing some of your health information, providers (like hospitals, clinics, and doctors) who are our members will be able to save you some time and treat you better. If you don’t sign this, though, then the law won’t let us share it.
☻ Why does this authorization mention HIV/AIDS, mental health or substance abuse information specifically?
This is because we have to let you know that if you have been tested or treated for these illnesses, then this information may be included in the information that is shared.
☻ Does this authorization give the ICC permission to share my personal health information with anyone outside of the ICC?
No. The only people who will be able to see it are the ICC members, the people who help them provide health care to you, such as doctors, and people who work for the ICC.
☻ If I sign, will the ICC share my information with the U.S. Government?
No. This information is confidential, and it will only be shared with ICC members.
☻ If I give permission, won’t ICC members be able to look at my information whenever they want, even if I’m not getting care?
Our rule is that only a person who is giving you health care will have your permission to see your information. We have a number of ways to help prevent someone from violating this rule, but if someone does violate it, we will be able to tell you who violated it and when it happened.
☻ What if I sign the authorization at one place, and then need to get care at another place. How long will it take for my information to get there?
The first time you give us permission to share your information, it will take about two weeks for it to get into our system. After that, it will be available whenever and wherever you need care in the ICC system, and it will be updated automatically.
☻ What happens if I lose the card you gave me after I signed the authorization?
The card is valuable because it may help you get health care more easily, so you should keep it safe and show it whenever you visit an ICC provider for health care. If you do lose it, we can replace it the next time you visit an ICC provider.
☻ What if I sign, but then change my mind?
Write us and tell us that you want to “revoke” the authorization (or do it the next time you get health care from an ICC member). Then throw away the card.
☻ Can I get copies of any of my health information that is shared?
Yes. All you need to do is ask your provider or ask us directly.
☻ Will I still get care if I don’t sign?
Yes. You don’t have to sign to get care.
☻ How do I contact the ICC if I have questions or want more information?
Our address is 1213 North IH 35, Austin TX 78702. Our phone number is 927-2677.
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We hope that you will feel comfortable signing the Authorization. However, If you decide not to sign it, it will help us if you will give us the reason. Please tell us, but do not sign your name.
I REFUSED TO SIGNED THE AUTHORIZATION BECAUSE:
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SEND TO: Sandy Coe, Director of Research, ICC, 1213 North IH-35, Austin, TX 78702