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  • SPARKS CENTER FOR DEVELOPMENT & LEARNING DISORDERS AUTHORIZATION FOR USE OR DISCLOSURE OF INFORMATION

    I hereby authorize the use or disclosure of my protected health information (“PHI”) as described below. This Authorization includes any information relating to drug and/or alcohol abuse/treatment, communications with psychiatrists or psychologists, or records pertaining to sexually transmitted diseases, if they are a part of my medical record. I understand that this authorization is voluntary. Once this information has been disclosed, it may be subject to re‐disclosure and no longer be protected by federal privacy regulations.

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  • Person / Organization Providing Information:

  • Person / Organization Receiving Information:

  • Notice
    If I request records in electronic form, I understand that the records on the CD or available via email/secured portal will be encrypted to help protect my privacy and the security of my health records and that I will be furnished with the manner in which to access those encrypted records. UAB Health System is not responsible for the privacy and security of the electronic records on the CD or in an email once they are received by the intended recipient.

  • The client or the client’s representative must read and initial the following statements:

    • I understand that I have a right to revoke this authorization at any time.
    • I understand that if I revoke this authorization, I must do so in writing and present my revocation to the entity privacy coordinator.
    • I understand that the revocation will not apply to information that has already been released in response to this authorization.
    • I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.

  • I understand that I may revoke this authorization at any time by notifying the UAB Privacy Officer in writing, but if I do, it will not have any affect to the extent UAB took action in reliance on the authorization.

  • I understand that UAB may not condition the provision of treatment, payment and enrollment in a health plan or eligibility for benefits on signing this authorization, except under the following circumstances:

    • Participating in research projects can be conditioned on my signing an authorization to use and disclose PHI in the research.
    • Initial enrollment in health plans can be conditioned on signing an authorization for the health plan to review PHI to make eligibility determinations.
    • Furnishing healthcare services to me at the request of a third party can be conditioned on me signing an authorization for disclosure of the PHI to the third party requesting the treatment.

  • If I fail to specify an expiration date or event, this authorization will automatically expire six (6) months from the date on which it was signed.

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