Release of Information
Release of Information for Care Coordination
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I hereby request and authorize the use and disclosure of any and all information obtained through Physicians CareConnection (including but not limited to protected health information and records of substance abuse (including alcohol/drug abuse), mental health/illness and HIV related information (including AIDS testing) to Central Ohio HUB (and its network of care coordination agencies and healthcare providers, including Healthcare Collaborative of Greater Columbus, Hospital Council of Northwest Ohio, The Ohio Department of Health, and Medicaid Managed Care Plans (CareSource, Molina, United Healthcare Community Plan, Paramount, and Buckeye)) and the Healthy Beginnings at Home (HBAH) program, including Celebrate One, Columbus Metropolitan Housing Authority, Homeless Families Foundation CompDrug, the OSU Wexner Medical Center, and The SMRT Columbus Rides for Pregnant Mothers program.The information may be communicated in writing and verbally.I understand that the disclosure of this protected health information with the entities listed on this form is to help my care team share general information about my family’s needs and services I utilize as it pertains to my care plan. I understand the care team will only disclose information that is necessary to provide me with integrative care coordination. This information will be collected and stored on the databases of the entities listed above.This authorization will expire 2 year(s) from the date of my signature below. I understand that I may shorten, extend or revoke this authorization at any time by notifying:Physicians CareConnection Attn: Privacy Officer 1390 Dublin Road Columbus, Ohio 43215. This authorization and request is fully understood and is made voluntarily on my part. I understand that information disclosed as related to this authorization may be subject to re-disclosure by the recipient of the information. I release Physicians CareConnection, its employees, agents and representatives of any legal liability that may arise from the release of information. *
I authorize Physicians CareConnection to send me text, email and voice messages. This includes (but is not limited to) treatment- or care-related reminders and health education information. *
Enter Your Full Name (First, Middle, and Last Name) OR the Minor's Full Name if this application is for a Minor, Below: *
DATE Signed: *
If you are the parent or legal guardian of the minor, please fill in your FULL NAME (First, Middle and Last Name):
If you are the parent or legal guardian of the minor, please state your relationship to the minor:
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