Authorization to Use and Release Protected Health Information for the HCU Back to Care Mentor Program

What is the purpose of this form?

Federal privacy laws protect the use and release of your identifiable health information, which is called protected health information. Under these laws, your protected health information cannot be used or disclosed to HCU Network America for this program unless you give your permission. You don’t have to sign this form. However, if you decide to participate in this program, you must agree to this form. This form will describe the ways that HCU Network America and program coordinators will use your protected health information for the program.

What protected health information will be used and released?

If you give your permission and agree to this form, you are allowing HCU Network America to use and release certain kinds of health information about you for the purposes of this program: “HCU Back to Care Program”.

The information that will be used and released for this program includes all information about you that will be collected during the study for program purposes and the health information about you that you provide that is related to the program. For this program, this information is: demographic information, laboratory test results, questionnaire results, and medical history.

Who will use my protected health information and to whom will it be released?

Your protected health information may be released to the following:

• HCU Network America and associated volunteers so they can conduct the HCU Back to Care Program, evaluate the program, and expand the program.

Once your protected health information is released outside of the HCU Network America (e.g., to associated volunteers, medical advisors) the information may not be protected by federal privacy laws. HCU Network America will make every effort to de-identify any information before it is released.

Does my permission expire?

This permission does not have an expiration date.

Can I cancel my permission?

You may cancel your permission at any time. If you have questions or want to cancel your permission, please contact: Danae’ Bartke, Executive Director, HCU Network America, 15 S. Mallory Ave, Batavia, IL 60510 (Dbartke@hcunetworkamerica.org ) 630-360-2087. If you cancel your permission, you may no longer be in the program. If you cancel your permission, information that was collected and released before your cancellation may continue to be used and released as needed to maintain the reliability of the program.