I have reviewed the Notice of Use and Disclosure Practices.
I understand that the requested Protected Health Information, criminal background information, and rental history will be used by Affinity Residential Care for the purpose of home health care.
I hereby authorize verbal and written communication from Affinity Residential Care and in addition, agree to release:
The following portions of my clinical record:
- History and Physical
- Discharge Summary
- Consults
- Plans of Care
- Current/ Past Progress Notes
- Mental Health Records
- Chemical Dependency Records
- Operative Reports
- Health Care Directives
- Medication List (including Pharmacy Communication)
- Physician's Orders
- Flow Sheets
- POLST (Health Care Directive)
- Laboratory Results (All)
- Radiology Reports (All)
And the following portions of other records to Affinity Residential including:
- Criminal Background Check via BCA or other sources
- Rental History Verifications within the last 5 years
- Case Management Records
Please read through the declaration below and sign and date at the bottom.
I understand that the records will be used to continue evaluation or treatment, coordinate services, and determine eligibility for services.
I understand that my records are protected by data privacy regulations. Alcohol and drug abuse records may be protected by Federal Law (42 CFR Part 2). These records cannot be released without my consent unless specifically directed by law.
I understand that I have the right to refuse to sign this consent.
I understand that I may withdraw or revoke this consent at any time if the action it authorizes has not been carried out.
I understand that this consent expires one year from the date I signed it.
A copy of this authorization shall be considered as effective and valid as the original.