Areti Health

Authorization to Retrieve and Disclose Protected Health Information

I give permission to Areti Health Inc to GIVE my healthcare information to:

Legal Purposes Transfer of Care

Other: To evaluate clinical research eligibility

In order to adequately evaluate clinical research eligibility I agree to the transfer of my: Entire Medical Record

This includes Problem Lists, Medication History, Laboratory/Pathology Results, Surgery and Procedure History, Imaging Results, Hospital Documents, Immunizations, Consultant Reports, Behavioral Health Records, Transfer of Care, Radiology Reports, Dental Records, and Office Visit Notes

Areti Health will retrieve records for the last 10 years unless otherwise stated.

If I have been diagnosed or treated for any of the following, I understand that the disclosing entity needs my specific consent. Indicate whether you DO or DO NOT authorize the release of protected health information for each of the following by initialing the appropriate box.

I DO

I DO NOT

DISORDER PROGRAM RECORDS AND INFORMATION PROTECTED BY 42 C.F.R PART 2.

Authorize the release of PHI regarding treatment for SUBSTANCE USE

Authorize the release of PHI regarding treatment for MENTAL HEALTH AND BEHAVIORAL HEALTH. I understand that I have the right to review any medical records containing PHI related to my mental and behavioral health that are maintained by licensed mental health facilities or agencies at any reasonable time before deciding to authorize the disclosure on this form.

Authorize the disclosure of HIV/AIDS INFORMATION, INCLUDING test results. I understand that there are potential risks associated with the disclosure of HIV/AIDS information including but not limited to discrimination and changes in family and social relationships.

I can withdraw my consent at any time by completing a revocation form available at https://www.aretihealth.com, subject to the right of any person who acted in reliance of this authorization before receiving notice that it was revoked. I can refuse to disclose some or all my records. But if I do so, it could result in an improper eligibility evaluation or other adverse consequences. Partial or incomplete records will be labeled as such to inform the provider receiving them of their status. The health center will not withhold treatment whether I provide this permission form or withdraw my consent to disclose Protected Health Information except as authorized by law. I am entitled to a copy of this authorization form. There is the potential that information disclosed pursuant to this authorization may be redisclosed by persons or entities receiving the information and that, as a result, the information may no longer be protected. I permit Areti Health Inc. to use this form to make additional disclosures of information permitted by this form. This form will expire one year from the date signed unless I revoke my permission sooner or provide an earlier expiration date. If you would like to provide an expiration date, please inform your health center.

I, the undersigned, hereby authorize the disclosing entity and its designated employees or agents to release/obtain/discuss medical information from my health record.

*** Signature by an authorized representative certifies to the disclosing entity that such person has the legal authority indicated to authorize disclosure of the patient's information and records on behalf of the patient.

If this authorization authorizes disclosure of substance use disorder program information protected by 42 C.F.R. Part 2: Notice to Recipient of Prohibition on Redisclosure: This record which has been disclosed to you is protected by Federal confidentiality rules (42 CFR part 2 These rules prohibit you from using or disclosing this record, or testimony that describes the information contained in this record, in any civil, criminal, administrative, or legislative proceedings by any Federal, State, or local authority, against the patient, unless authorized by the consent of the patient, except as provided at 42 CFR 2.12(c5) or as authorized by a court in accordance with 42 CFR 2.64 or 2.65. In addition, the Federal rules prohibit you from making any other use or disclosure of this record unless at least one of the following applies: (i) further use or disclosure is expressly permitted by the written consent of the individual whose information is being disclosed in this record or as otherwise permitted by 42 CFR part 2; (ii) you are a covered entity or business associate and have received the record for treatment, payment, or health care operations; or (iii) you have received the record from a covered entity or business associate as permitted by 45 CFR part 164, subparts A and E. A general authorization for the release of medical or other information is NOT sufficient to meet the required elements of written consent to further use or redisclose the record (see 42 CFR 2.31