Carls Center for Clinical Care and Education
1101 Health Professions Building Audiology Clinic
Mount Pleasant, MI 48859 Speech-Language Pathology Clinic
Phone: (989) 774-3904 Summer Specialty Clinics
Fax: (989) 774-1891 Psychological Training and Consultation Center
Physical Therapy – Hands for Health
Authorization for Use of Protected Health Information
For Uses Other Than Treatment, Payment or Health Care Operations
Client Name ______M.R.#:
(Please Print Clearly)
1. I authorize CMU ______to disclose the following health information about me:
Revised 08/2006 – CLF
HIPAA 2
Carls Center for Clinical Care and Education
q Audiology/Hearing Reports
q Billing Statements
q Claims Resolution
q Consultations
q ECG(s)
q Health Services Reports
q History & Physical Exam
q Immunization Record
q Laboratory Reports
q Media Release
q Pathology Reports
q Radiology Reports
q Speech-Language Reports
q Psychological Reports
q Treatment Documentation
q Other:______
Revised 08/2006 – CLF
HIPAA 2
Carls Center for Clinical Care and Education
2. The information to be disclosed is PHI from ______to ______(dates).
3. This information may be disclosed to (please give name, address and tele. # of recipient):
Revised 08/2006 – CLF
HIPAA 2
Carls Center for Clinical Care and Education
______
Revised 08/2006 – CLF
HIPAA 2
Carls Center for Clinical Care and Education
4. This information may be disclosed for the purpose of:
q At my request, or
q Other: ______
5. The information may be disclosed until (ending date) ______. If this date is left blank, the authorization will automatically expire one year from the date I sign below.
6. I understand that if the person(s) or entity(ies) that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be redisclosed and is no longer protected by those regulations. Therefore I release Central Michigan University, its faculty and staff from all liability arising from the disclosure of my health information.
7. I understand that I may inspect or request copies of any information disclosed by this authorization
8. I understand that I may revoke this authorization by notifying, in writing, CMU ______, except to the extent that action has been taken on it.
9. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment or my eligibility for benefits from CMU.
10. I understand that the information in my health record may include information about behavioral or mental health services, and
treatment for alcohol and drug abuse.
Revised 08/2006 – CLF
HIPAA 2
______
Client/Patient/Employee Signature Date
______
Guardian Signature, if appropriate Relationship to Client
Revised as of: 4/7/03