Release & Electronic Communication - Eating Disorder Recovery Specialists

Which describes you:*

I am the patient
I am the parent of the patient

Patient's Name

First Last

Parent's Name

First Last

Sex

Male
Female

Date

This authorization must be completed by the patient or his/her personal representative to use/disclose protected health information, in accordance with State and federal laws and regulations. Information may be released pursuant to this authorization to the parties identified herein who have a demonstrable need for the information, provided that the disclosure will not reasonably be expected to be detrimental to the patient or another person. A separate authorization is required to use or disclose confidential HIV related information.

PART 1: Authorization to Release Information

Description of Information to be Used/Disclosed:

Progress updates, clinical information, and/or financial information

1. Purpose or Need for Information: This information is being requested:

by the individual or his/her personal representative for release to a person or entity with a demonstrable need for the information.

2. The purpose of the disclosure is (please describe):

Coordination of clinical care

From: Name, Address, & Title of Person/Organization/Facility/Program Disclosing Information

Eating Disorder Recovery Specialists, 459
Columbus Ave, Suite 124, New York, NY
10024 - 855-525-2766

A. I hereby permit the use or disclosure of the above information to the Person/Organization/Facility/Program(s) identified above. I understand that:

1. Only the information described in this form may be used and/or disclosed as a result of this authorization.

2. This information is confidential and is protected under federal privacy regulations (HIPAA) and the NYS Mental Hygiene Law and cannot legally be disclosed without my permission.

3. If this information is disclosed to someone who is not required to comply with HIPAA, then it could be redisclosed and would no longer be protected by HIPAA. However, this information will still be protected under the NYS Mental Hygiene law, which prohibits this information from being redisclosed by anyone who receives it unless the redisclosure is permitted by the NYS law (Mental Hygiene Law §33.13).

4. I have the right to revoke (take back) this authorization at any time. My revocation must be in writing on the form provided to me by Eating Disorder Recovery Specialists. I am aware that my revocation will not be effective if the persons I have authorized to use and/or disclose my protected health information have already taken action because of my earlier authorization.

5. I do not have to sign this authorization and that my refusal to sign will not affect my abilities to obtain treatment from the New York State Office of Mental Health, nor will it affect my eligibility for benefits.

6. I have a right to inspect and copy my own protected health information to be used and/or disclosed (in accordance with the requirements of the federal privacy protection regulations found under 45 CFR §164.524 and NYS Mental Hygiene Law §33.16.

B-1. One-Time Use/Disclosure: I hereby permit the one-time use or disclosure of the information described above to the person/ organization/facility/program identified above.

My authorization will expire:
12 Months from this Date

Facility/Agency Name:
Eating Disorder Recovery Specialists

B-2. Periodic Use/Disclosure: I hereby authorize the periodic use/disclosure of the information described above to the person/organization/facility/program identified above as often as necessary to fulfill the purpose identified above.

My authorization will expire:
When I am no longer receiving services from Eating Disorder Recovery Specialists

C. Patient Signature: I certify that I authorize the use of my health information as set forth in this document.

Signature of Patient or Personal Representative

Date*

Patient’s Name

First Last

Personal Representative’s Name

First Last

Description of Personal Representative’s Authority to Act for the Patient

(required if Personal Representative signs Authorization)

D. Witness Statement/Signature: I have witnessed the execution of this authorization and state that a copy of the signed authorization was provided to the patient and/or the patient's personal representative.

WITNESSED BY: Eating Disorder Recovery Specialists

Authorization Provided To:

Date

To be Completed by Facility:

Signature

Title

Date

Agreement Form for Electronic Communications

Secure electronic messaging is always preferred to insecure email for more sensitive PHI, but under specific circumstances, insecure email communication containing protected health information (PHI) may take place between Eating Disorder Recovery Specialists and clients and/or family members. This email communication may be used if both parties agree on this communication method and this form is completed and signed by both the provider and the patient or the patient’s personal representative (if appropriate).

A copy of this form and all email communication will be filed in the patient’s Record and a hard copy of this form will be provided to the patient. This agreement is limited to communications using the email addresses listed below.

PROVIDER AWARENESS:

Standard email and text messaging are not a 100% secure means of communication, so as the provider I will use the minimum necessary amount of protected health information when responding to your questions or communicating information to you or designated supports, as signed in your Consent(s) for Release.

PATIENT AWARENESS:

Please note that most standard email and text messaging does not provide a secure means of communication. There is some risk that any protected health information contained in email may be disclosed to, or intercepted by, unauthorized third parties. Use of more secure communications, such as phone or fax, is the preferred method of communication. Please note that we are using HIPAA compliant software for email messaging, but recipients may not be.

By reading and signing this form, the provider and I understand and are willing to accept the risks involved with insecure email and texting of communication of my protected health information.

Patient's Phone Number

Patient's Email Address

Signature

Client's Name

First Last