HIPAA Disclosure and Release of Information
By signing below, I authorize Pathways in Aging, LLC to use or disclose protected health information about the individual named above, as described below.
1. The following organization(s) are authorized to make the disclosure:
Pathways in Aging, LLC
2. The type of information which may be disclosed includes:
Medical notes, medications, labs/diagnostic tests, assessments, case notes, insurance, demographic
3. Dates of Service: X All □ Other
4. The information will be used or disclosed for the following purpose(s):
Care Coordination
5. This authorization will expire upon discharge from Pathways in Aging.
6. I understand that I have a right to change or revoke this Authorization at any time by providing written notification to Pathways in Aging. I understand that the revocation will not apply to information that Pathways in Aging has already released in response to this Authorization.
7. I understand that authorizing the use or disclosure of the information identified above is voluntary and at my request. I understand that my receipt of services from Pathways in Aging is not in any way conditioned on whether I sign this Authorization.
8. I understand that once information disclosed pursuant to this Authorization has been disclosed, it may be re-disclosed by the recipient and the information may not be protected by federal privacy laws or regulations following disclosure.
9. Pathways in Aging will retain a copy of this Authorization with my records for seven (7) years.
10. I understand that I am entitled to obtain a copy of this Authorization.