AUTHORIZATION FOR USE AND DISCLOSURE OF

PROTECTED HEALTH INFORMATION

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.

This Authorization For Use and Disclosure of Protected Health Information is given by the undersigned on the date appearing below:

I understand that the Coordinated Health System of Jefferson County, Inc. (CHS) conducts a program entitled HealthPlus+ in cooperation with certain health care providers and other entities, including Bessemer Carraway Medical Center, Birmingham Healthcare, Carraway Methodist Medical Center, Coordinated Health System of Jefferson County Resource Center, Eastern Health System, Inc. dba: Medical Center East, Jefferson County Board of Health, the Jefferson County Medical Society, Jefferson Health Systems/Cooper Green Hospital, Montclair Baptist Medical Center, St. Vincent’s Medical Center, University of Alabama Hospital and Princeton Baptist Medical Center, the purpose of which is to reduce duplication of health and health related services in this community, to facilitate referrals for treatment and utilization of the public health clinics, to establish the concept of the Medical Home and to otherwise direct individuals for care in appropriate settings.  In order to perform this function, it is necessary for CHS to disclose personal, financial, and medical information and other Protected Health Information to the above and other entities.  I authorize CHS, and in particular Princeton Baptist Medical Center, to disclose to, to use and to give the above health care organizations access to my personal, financial, and medical information and other Protected Health Information acquired incident to my treatment or payment for services rendered to me, or incident to their respective operations, including the right to use such Protected Health Information for treatment, payment and for purposes of such operations.

ELECTRONIC DATABASE.  I understand that my Protected Health Information is being entered into an electronic database.

·         I give permission to CHS and its affiliated entities to obtain information from and release Protected Health Information to state agencies, banking institutions, employers, federal agencies, and other sources incident to their operations and incident to services rendered to me.

·         It is my understanding that my Protected Health Information is subject to review by State and/or Federal Quality Control entities and may be disclosed to such entities.

·         I give permission for the release of Protected Health Information for those purposes directly related to the administration of CHS programs. These purposes include, but are not limited to, establishing eligibility for HealthPlus+, determining the amount of medical assistance I may receive, the providing of services, utilization management and investigation of program violations. I understand that my social security number and the social security numbers of other persons in my household may be given to the Social Security Administration, Internal Revenue Service and other agencies and organizations to check my employment status, amount of wages and eligibility.

·         I consent to use and disclosure of this Protected Health Information to establish appointments for me, and assist in making referrals for me, to conduct follow up contacts with me incident to such appointments, to provide treatment and treatment related services and to evaluate or suggest treatment alternatives.

·         I understand that information once disclosed may be subsequent to redisclosure by the recipient and no longer protected by Privacy Rules.

·         I understand that CHS does not condition enrollment on execution of this Authorization except where permitted by law.

·         I understand that CHS will receive no direct or indirect remuneration from any third party as a result of this disclosure.

·         I have the right to opt-out of disclosure of information to any facility directories (including disclosure to clergy) or to family members or others who may be assisting with my care should I receive inpatient care at any hospital participating with CHS.

·         I realize that it may become necessary for CHS or a participating institution to disclose Protected Health Information to a family member incident to my location, treatment or payment for services should I be absent or incapacitated.  I authorize CHS or its affiliated institution to make such disclosures as it deems in my best interest in exercise of its professional judgment.

This Authorization shall remain in force until I notify CHS in writing that it has been withdrawn.

Date                                                         Patient Signature                     Witness Signature

                                                                Patient Signature If by a Representative

The Coordinated Health System of Jefferson County, Inc.

2121 8th Avenue North, Suite 200

Birmingham, Alabama 35203

(205) 327-8254