AUTHORIZATION TO USE AND DISCLOSE HEALTH INFORMATION
TO COMMUNICATE ABOUT CERTAIN PRODUCTS AND SERVICES
Patient Name: ______ID Number: ______
Date of Birth: ______
We understand that information about you and your health is personal, and we arecommitted to protecting the privacy of that information. Because of this commitment, wemust obtain your written authorization before we may use or disclose your protectedhealth information to communicate with you, or to assist others to communicate with you,about the products and services described below. This form provides that authorizationand helps us make sure that you are properly informed of how this information will be
used or disclosed. Please read the information below carefully before signing this form.
USE AND DISCLOSURE COVERED BY THIS AUTHORIZATION
A representative of Stony Brook Medicine must answer these questionscompletely before providing this authorization form to you. DO NOT SIGN A BLANKFORM. You or your personal representative should read the descriptions below beforesigning this form.
Who will disclose the information? The person(s) or class of persons authorized todisclose the information is described below.
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Who will use and/or receive the information? The person(s) or class of personsauthorized to use and/or receive the information is described below.
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What information will be used or disclosed? The description below should be in enough detail so that you (or anyorganization that must disclose information pursuant to this authorization) can understandwhat information may be used or disclosed.
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Note: The Authorization for the Use or Disclosure of any HIV-related information (which is any information indicating that you have had an HIV-related test, or have HIV infection, HIV-related illness or AIDS, or any information which could indicate that you have been potentially exposed to HIV), must be obtained using the appropriate “NYS Department of Health HIPAA Compliant Authorization for the Release of HIV-Related Information”
What is the purpose of the use or disclosure? Your health information will be used ordisclosed by or to the persons specified on this authorization form in order to provideinformation about the following products or services.
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Will the Medical Center receive any direct or indirect remuneration for communicating with you, or assisting others to communicate with you, about these products or services?
Yes No
When will this authorization expire? The date or event that will trigger the expirationof thisauthorization should be described below
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SPECIFIC UNDERSTANDINGS
By signing this authorization form, you authorize the use or disclosure of your protectedhealth information (PHI) as described above. This information may be redisclosed if therecipient(s) described on this form is not required by law to protect the privacy of theinformation, and such information is no longer protected by federal health informationprivacy regulations.
If you are authorizing the release of HIV-related information, you should be aware thatthe recipient(s) is prohibited from redisclosing any HIV-related information without yourauthorization unless permitted to do so under federal or state law. You also have a rightto request a list of people who may receive or use your HIV-related information withoutauthorization. If you experience discrimination because of the release or disclosure ofHIV-related information, you may contact the New York State Division of Human Rights
at (800) 523-2437 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for protecting your rights.
You have a right to refuse to sign this authorization. Your health care, the payment foryour health care, and your health care benefits will not be affected if you do not sign thisform.
You have a right to see and copy the information described on this authorization form inaccordance with Medical Center policies. You also have a right to receive a copy of this formafter you have signed it.
If you sign this authorization, you will have the right to revoke it at any time, except tothe extent that the Medical Center has already taken action based upon your authorization. Torevoke this authorization, please write to:
HIPAA Privacy Officer
Stony Brook University Hospital
Stony Brook, NY 11794-9296
SIGNATURE
I have read this form and all of my questions about this form have been answered. By
signing below, I acknowledge that I have read and accept all of the above.
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Signature of Patient or Personal Representative
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Print Name of Patient or Personal Representative
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Date
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Description of Personal Representative’s Authority