It is important that you read the following. If there is anything that you do not understand, or if you have any questions, be sure to ASK.
Welcome to Ecornerstone, a system that collects and uses data on a wide range of state programs for individuals. These programs include WIC (Women, Infants and Children); immunizations; Case Management; Prenatal and Postpartum Care; Pediatric Primary Care; Early Intervention; Breast and Cervical Cancer; Diabetes Control; Healthy Families Illinois; and Youth Programs including Comprehensive Community-Based Youth Services, Crossroads, and Teen REACH.
We are seeking your permission to share information about the participant for enrollment and case-management purposes. This information includes the participant’s participation in any of the programs listed above. Based on the information, we may determine that the participant could benefit from other state-funded programs. We will also use the information in order to provide and pay for services for which the participant is enrolling, and to refer the participant for other necessary services.
We protect personal information we collect about the participant by maintaining physical, electronic and procedural safeguards. Program participation information will be shared only with authorized staff with a direct need to know about the participant. Information may also be released by necessary for participation authorization, and for program audit and evaluation purposes. Necessary information, without any participant’s name, will also be sent to federal and/or State agencies that fund the program.
By signing this Consent form, you agree to allow the information as described in this Consent to be used by this agency/clinic as described in the Consent. The person(s) receiving this information has(ve) a legal and ethical duty to keep the information confidential and private and not to release it to anyone else except as described in this Consent, without your written permission, unless the law allows it.
A.) I hereby authorize Bella Ease to compare data already entered in the computer system regarding any other of the above programs that the participant may have participated in, with data about the participant collected during this enrollment/registration process, and to release data as necessary to provide the service requested and the referrals necessary.
B.) This consent covers all the medical, social and financial information about the participant, including participant background and demographic information; health visit information; medical and developmental history; prenatal birth, and postpartum data; infant/child visit data; immunization records; participant risks and protective factors; problems or factors that prevent the participant from receiving proper medical care; appointments made and services received; goals and care plan; WIC food packages; program information; information required by the federal Maternal and Child Health Block Grant Program; Youth programs; and Early Intervention Program, but only as relevant to the service being provided and as necessary to accomplish the above purposes.
C.) This consent does not cover information about the diagnosis of or treatment for mental health, AIDS, HIV, sexually transmissible diseases, alcoholism, and drug abuse which will not be released to other programs pursuant to this consent.
D.) I am making this consent within the limits of my legal authority. I understand that I may revoke this consent in writing at any time, but that revoking this consent will not cancel what was done before I revoked it. I also understand and agree not to hold this agency or the Illinois Departments of Human Services or Public Health liable for the release of any information about me in accordance with the terms of this consent form or as allowed by law.
E.) A photostatic copy/facsimile of this consent will be as valid as the original.