B2H Authorization for Release English

Bridges to Health Pathways Program

Authorization for Release of Health information for use in the Briges to Health Pathways Community HUB Program

Participant Name

First NameLast Name

Date of Birth

Gender

MaleFemale

Phone Number

(Area Code) Phone Number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

By my signature below, I permit Columbia Gorge Health Council (“CGHC”) and each entity that has signed, or will sign, a Bridges to Health Pathways Program Services Agreement with CGHC (collectively, “Agencies”) to use and disclose all of my protected health information to CGHC and all other Agencies, except as excluded below, for the purposes stated in this Release. I understand that the Agencies are healthcare provider organizations and non-healthcare provider organizations. I understand that I have the right to obtain a list of the current Agencies in the Bridges to Health Pathways Community HUB project from CGHC upon request.

The following one or more Agencies are specifically excluded from this Release:

List (if applicable)

Release and Use of Protected Health Information

I am participating in the Pathways Community Hub Project. I authorize the disclosure and use of all of my protected health information in accordance with this Release. If the information to be used or disclosed contains any of the types of records or information listed below, additional laws relating to the use and disclosure of the information may apply. I understand and agree that this information will only be used and disclosed if I place my initials in the applicable space next to the type of information.

HIV/AIDS Information

Initial

Genetic Testing Information

Initial

Mental Health Information

Initial

Drug/Alcohol diagnosis, treatment, or referral information

Initial

Expiration of Release:

By signing this form, I am saying that I understand and agree that this authorization will expire WITHIN 2 YEARS FROM THE DAY SIGNED or when my participation in the Bridges to Health Pathways Community HUB program ends, whichever occurs last. My participation in the program will end at the end of the program or when I revoke my participation in the program by submitting written notice to CGHC.

By signing this form, I am saying that I understand I can cancel this authorization at any time and for any reason, by giving written notice to the following Contact Office:

Contact Office: Columbia Gorge Health Council

Address: 610 Court Street The Dalles, OR 97058

Email: B2H@gorgehealthcouncil.org

I understand that this cancellation does not apply to any action that CGHC or the Agencies have taken in reliance on the Release.

I also understand that:

- If I want to be part of the Bridges to Health Pathways Community HUB project, I must sign this authorization.

- I am not required to sign this authorization in order to receive treatment or payment or to enroll or be eligible for benefits.

- My health care or payment for health care will not be affected if I refuse to sign.

- Information disclosed under this authorization form may be re-disclosed by the recipient and when re-disclosed, may no longer be protected by federal privacy regulations. However, I also understand that federal or state law may restrict redisclosure of HIV/AIDS information, mental health information, genetic testing information and drug/alcohol diagnosis, treatment or referral information.

- A copy of this authorization may be used with the same effectiveness as this original form.

Signature of Participant (or legal guardian for the participant)

Date

Time

Hour Minutes

AM/PM Option

Name of Legal Representative for the Participant

NameLast Name

Relationship of Legal Representative to Patient