AUTHORIZATION for the USE and 2018-2026

898. 3000 ECMC. EDU Health Information Management Department G30 716. 898. 3257/3258 It is understood that any disclosure is bound by 42 CFR Part 2 governing the confidentiality of alcohol and drug abuse patient records and that re disclosure of alcohol and drug abuse information to a party other than the one designated above is forbidden without your additional written authorization. If this authorization involves alcohol and drug abuse patient information it shall expire six 6 months from the date signed unless a different time period event or condition is specified in Section 2 below. AUTHORIZATION FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION PG 1 OF 3 Name Med* Rec* Visit Service Date Date of Birth Insurance Service Time Age Room This form implements the requirements for patient authorization to use and disclose health information protected by the federal health privacy law 45 C. F*R* parts 160 164. Except as otherwise permitted or required by the privacy law a healthcare provider subject to the privacy law may not use or disclose protected health information without an authorization that complies with the requirements of 45 C. F*R* Section 164. 508. Patient/Resident Name Date of Birth Address Phone E Mail address initials Please initial here if you would like your records electronically I hereby authorize the use or disclosure of protected health information as follows 1. The information that may be used or disclosed includes initial applicable line All treatment records. If this is initialed patient must also separately initial the categories below if Behavioral Health records Drug and Alcohol Treatment records and/or HIV related records are to be used or disclosed* Record of treatment during the following time period Behavioral Health/Psychiatric records discharge summary and information below xh Yyzx xh yzx xh y zx If you authorize the release of behavioral health information the disclosing party named above will disclose such information in accordance with Sections 33. 13 and 33. 16 of the Mental Hygiene Law. Drug and Alcohol Treatment records discharge summary and information indicated below ERIE COUNTY MEDICAL CENTER HEALTHCARE NETWORK Rev* 2/13 LGL*100 Erie County Medical Center Corporation 462 Grider Street Buffalo New York 14215 716. NOTE Any information disclosed through this form will be accompanied by Form ALC 440 Prohibition on Redisclosure of Insurance Concerning Alcoholism Patient. HIV Related records discharge summary and information indicated below Due to NYSDOH Chapter 308 of the Laws of 2010 HIV testing Law Mandated August 2010 all patients should be asked to initial this section from redisclosing any HIV related information without your authorization unless permitted to do so under federal or state law. You also have a right to request a list of people who may receive or use your HIV related HIV related information you may contact the New York State Division of Human Rights at 212 480 2493 or 1 800 523 2437 or the New York City Commission on Human Rights at 212 306 7450.