LINKING CLIENTS TO CARE AND SERVICES
Consent to Share Confidential Information
The Community Integration Collaborative is an effort to link HIV-infected persons to medical care in order to optimize their health and avoid further infections. Through this collaboration, services will be provided to you based on your needs. However, to give you the best possible care, information will be needed from other doctors or agencies that are providing or have provided you medical care or any type of assistance. Please complete this form to assist us in serving your needs. Refusal to complete the form does not prevent you from accessing services through our agency. Please ask for assistance if needed.
I____________________________, hereby give my full consent to (please check those that apply), to provide and obtain information concerning past assistance and/or services received by me:
| ABC Agency | ____________________________ |
|
AIDS Drug
Assistance Program (ADAP)
|
____________________________ |
|
Children's
Medical Services
|
____________________________ |
|
Case Management
R-Us
|
____________________________ |
|
Other |
____________________________ |
The identified agency above shall obtain and release the following CONFIDENTIAL information
| Client Initial | Specific Information | Client Initial | Specific Information |
| ________________________________ | _________________________ | _______ | ____________________________ |
| ______________________________ | HIV Status____ ____________ | _______ | Other________________________ |
| ______________________________ | Pregnancy Status______________ | _______ | Other________________________ |
I hereby authorize all information requested to be released to and/or obtained from the specified agencies or individuals below. Information will be held strictly confidential & may not be re-disclosed by without my written consent.
|
Client
Initial
|
Agency
or Physician
|
Client
Initial
|
Agency
or Physician
|
| ______________________________ | ABC Agency | _____________ | AIDS Drug Assistance Program |
| ______________________________ | Case Management R-Us | _____________ | Children's Medical Services |
| ______________________________ | Private Physician__________ | _____________ | Other________________________ |
I understand that this authorization is ongoing and will remain in effect until the date, event or condition specified below, or until my consent is revoked:
___________________________________________________________________________________________(Specify Date, Event or Condition)
| __________________________________ | ______________________________________ |
| Signature of Client or Legal Representative | Relationship to Client of Legal Representative |
| __________________________________ | __________________________________ |
| Signature of Witness |
Date of Consent |
| __________________________________ | __________________________________ |
| Date Consent was Revoked by Client | Client's Initials |
Note to receiving agency(ies): This information has been disclosed to you from records whose confidentiality is protected by State Law. State Law prohibits you from making any further disclosure of such information without the specific written consent of the person to whom such information pertains or as otherwise permitted by State Law. A general authorization is not sufficient for this purpose.
April 30, 2003