WHO MAY DISCLOSE INFORMATION.
The agency I have named at the top of this form may disclose protected health information to ICANS.
WHAT MAY BE DISCLOSED.
By signing this consent, I specifically understand that protected health information or records will be released, used, disclosed, received, mutually exchanged or communicated to, by, among, or between any person, entity, or agency referenced in this authorization. I understand this information may include material protected under federal regulations governing confidentiality of alcohol and drug abuse patient records, 42 C.F.R. Part 2; the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 CFR Parts 160, 162 & 164; and Medicaid Regulations for safeguarding information, 42 CFR Part 431, Subpart F. Federal rules restrict any use of the information to criminally investigate or prosecute and to redisclose records relating to any individual receiving alcohol or drug abuse treatment.
PURPOSE AND EFFECT.
I understand this authorization will allow my/my child or ward’s treatment team to plan and coordinate services I need and will allow any person, entity, or agency referenced in this authorization to be actively involved in case coordination, evaluation, treatment, planning, or legal proceedings. I hereby request and give permission for an open exchange of information to, by, among, or between, any person, entity, or agency referenced in this authorization. A photocopy or exact reproduction of this signed authorization shall have the same force and effect as this original.
REVOCATION.
I also understand that I may revoke this Informed Consent at any time by submitting a Request to Restrict Access form to ICANSRestrictionRequests@dhw.idaho.gov. I acknowledge that revocation will prevent
future disclosure of information in ICANS but will not impact any disclosures that have previously been made in reliance upon the executed Informed Consent Release form.
EXPIRATION.
This authorization shall expire one (1) year from the date the Minor Client and Parent or Legal Guardian signs below.
CONSENT.
I understand that my information cannot be disclosed without my written consent, except as otherwise provided by law, and that federal and Idaho law will be followed for using and disclosing my ICANS information.
By signing this form, I am authorizing providers assessing, treating, or coordinating care for my child/ward to provide my child/ward’s information to ICANS. I understand that failure to sign this authorization may limit eligibility, enrollment, or treatment for my child/ward.
I have read this Informed Consent/had this Informed Consent read/explained to me and I acknowledge an understanding of the purpose for the release of information. I am signing this authorization of my own free will.