Consent to release information
MY RIGHTS – Regarding this Authorization
for The Hawaii Counseling and Education Center, Inc. to
DISCLOSE or RECEIVE PROTECTED HEALTH INFORMATION
I understand I do not have to sign this authorization in order to receive care and treatment from the Hawaii Counseling and Education Center, Inc. (HCEC). However, I also understand that if I withhold my signature – and for example if I don’t provide HCEC or my other health care providers with complete information about my past and present health status, or life circumstances, it may lessen the quality of care I am able to receive.
I understand that I do have to sign this authorization form when the purpose is to create health information for a third party. For example, if an employer or school administrator conditions my return to work or school on receipt of my current health status from my doctor or clinician, then I wouldn’t be able to return to work or school unless I authorized release of the necessary information.
I understand that I may revoke this authorization in writing. If I did, it would not affect any actions already taken by HCEC based upon this authorization. I may not be able to revoke this authorization if its purpose was to obtain insurance. Two ways to revoke this authorization are:
- Fill out a revocation form. The form is available from the office. or
- Write a letter to HCEC at Post Office Box 795, Pahoa, HI 96778 requesting revocation of the consent.
I understand there may be a risk of loss of privacy and confidentiality, by re-release of my protected health information (PHI): Once HCEC discloses your health information, the person or organization receiving it may re-disclose it. Privacy laws may no longer protect it. However, most healthcare providers / organizations are now required to follow the new federal privacy laws, so your privacy is now protected better than ever.
Please discuss with your clinician any questions or concerns you may have about your rights under the new privacy law, or about the potential re-release of your PHI. It is HCEC’s policy to follow the “Minimum Necessary” standard. We can release partial information, the minimum amount of PHI necessary to accomplish what is needed by the person or organization requesting it.
Effective Date: April 14, 2003