Consent to Release and Share Medical Records
Section I – It may be necessary to share some of your personal information in order to facilitate access to PrEP. By providing your personal information to Prevention 305 / Prevencion 305 (herein referred to as “P305”), you consent to allowing P305 to share your information with the medical professional(s) or healthcare organization(s) with which P305 has Memorandums of Agreement, Memorandums of Understanding, Business Associate Agreements in order to provide access to PrEP.
Section II – Health Information – By providing your information to us, you give P305 and its healthcare partners permission to: Disclose and receive your health records including, but not limited to, diagnosis, lab test results, treatment, and billing records for all conditions before and after the referral process. These include records of communicable diseases including, but not limited to, sexually transmitted infections, HIV, Hepatitis B/C, or any other conditions relevant to your care.
Section III – Reason for Disclosure – I accept that with the intention to access general care, or access to Pre-Exposure Prophylaxis (PrEP), or Post-Exposure Prophylaxis (PEP), or Treatment as Prevention (TaSP), or access to HIV-testing and Sexual Transmitted Infection (STI) testing, and any other relevant and necessary tests, P305 will share and receive information of my health status.
Section IV – Who Can Receive My Health Information – I give authorization for the health information discussed in section II of this document to be shared with healthcare organizations or social assistance programs, or other organizations that may not be covered by state/federal rules governing privacy and security of data and may be permitted to further share the information that is provided to them.
Section V – Duration of Authorization – This authorization to share my health information is valid from the date of my registration with P305 for the duration of care or until revoked.
I understand that I am can revoke this authorization to share my health data at any time and can do so by submitting a request in writing to firstname.lastname@example.org specifying my name, date of birth, phone number, and home address, or information necessary to prove my identity.
I understand that if my information has already been shared by the time my authorization is revoked, it may be too late to cancel permission to share my health data, and further revocation may need to be submitted to the healthcare partner with whom the information was shared.
I understand that I do not need to give any further permission for the information detailed in Section II to be shared.
When I share my information with P305, I understand that the failure to sign/submit this authorization or the cancellation of this authorization will not prevent me from receiving any treatment or benefits I am entitled to receive, provided this information is not required to determine if I am eligible to receive those treatments or benefits or to pay for the services I receive.
I have read and accepted these terms.
To further address concerns and potential violations, you can reach out to local officials. The local Department of Health Administrator for Miami-Dade is Dr. Yesenia Diaz Villalta, and the main number to reach the Administrator is 305-324-2400. The Administrator’s office email is email@example.com. The Equal Opportunity Director (Civil Rights) and Coordinator for the Americans with Disabilities Act is Dee Dee McGee. Her phone number is 850-245-4002 and her office can be reached by email at firstname.lastname@example.org.