I AUTHORIZE THE USE/DISCLOSURE OF HEALTH AND/OR OTHER IDENTIFYING INFORMATION ABOUT ME AS DESCRIBED BELOW:
Person(s) or Organization(s) authorized to provide the information:
Any related to my case
Person(s) or Organization(s) authorized to receive the information:
Kindness Between Friends, Inc
Specific description of the information that be may be used or disclosed (including date(s)):
Anything related to my case
Specific description of how the information will be used:
To help me obtain services
I understand this authorization will expire one year from today or when my case is closed, whichever comes first, but will not last more than one year.
I understand that I may revoke this authorization (except to the extent that the action was already taken in reliance to the signed authorization) at any time by notifying Kindness Between Friends in writing.
I understand that I can refuse to sign this authorization and it shall not impact my ability to receive programs or services or otherwise interact with Kindness Between Friends, however not all services may be available to me.
I may inspect or copy any information used or disclosed under this agreement.
I understand that if the person or organization that receives the information is not a healthcare provider or plan covered by federal privacy regulations, the information described above may be re-disclosed and would no longer be protected by these guidelines.