CONSENT TO THE USE AND DISCLOSURE OF PERSONAL HEALTH INFORMATION FOR TREATMENT, PAYMENT OR HEALTH CARE OPERATIONS

    I , understand and agree that Laila Way Inc. may use and disclose protected health information (including but not limited to name, address, health history, symptoms, examination and test results, diagnosis and treatment) for treatment, payment or health care operations.

    I understand and have been provided with a copy of the document entitled Notice of Information Practices which provides a complete description of potential uses and disclosures of my protected health information. I understand that I have the right to review the Notice of Information Practices prior to signing the consent.

    I understand that Laila Way Inc. reserves the right to change its privacy practices and will mail a copy of any revised notice to the address I’ve provided.

    I understand that I have the right to request that the Laila Way Inc restrict how protected health information is used or disclosed to carry out treatment, payment or health care operation. I further understand that the Program is not required to grant any request to restrict the use or disclosure of information. If, however, the Program agrees to a requested restriction, the restriction is binding on the Program.

    I agree that I have the right to revoke this Consent in writing.

    Authorization for Use or Disclosure of Health Information

    1. I , hereby authorize the Laila Way Inc. and its health and human services programs to use/disclose the following Protected Health Information from the records of:

    2. Organization information to be used or disclosed(organization name and Address) :

    3. This information is to be disclosed to Laila Way Inc. and staff associated with Laila Way INC. for the purpose of:

    Continuity of Care

    4. I understand this authorization may be revoked in writing at any time, except to the extent that action has been taken in reliance on this authorization (Program Office to add specifics of how individuals may revoke authorization). Unless otherwise revoked, this authorization will expire one year after the signed date of this release.

    5. The Laila Way Inc, its programs, services, employees, officers, and contractors are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized.

    6. I understand that Laila Way Inc and its health and human services programs will not condition treatment, payment, enrollment, or eligibility on the provision of this authorization.

    7. I understand that I may inspect or copy my personal health information and may also refuse to sign this authorization.

    8. Information disclosed pursuant to this authorization is subject to redisclosure by the recipient and is no longer protected by federal privacy regulations (This provision is necessary if redisclosure is possible).

    9. If this authorization is to be signed by a personal representative, please describe the authority to act for the individual.