I authorize Greater Community AIDS Project of East Central Illinois to disclose my name, identity, and identity documentation to Courtesy Motel for purposes of care coordination and shelter services
Information may be disclosed/obtained by Mail, In-Person, Phone, E-Mail or by Fax
It is my full understanding that the records and communications to be disclosed may include sensitive information such as evaluation, habilitation/treatment information for mental health, developmental disabilities, alcohol or substance use/abuse or HIV/AIDs.
I understand that the above-named agency/facility/person authorized to receive this information has the right to inspect and copy the information disclosed. I further understand that if the entity receiving this information is not a healthcare provider/ plan covered by HIPAA privacy regulations, the information described above may be re-disclosed and no longer protected by the HIPAA Regulations.
I understand that I may revoke this authorization; however, the revocation must be in writing and must be sent/given to the facility record's department. I understand that no revocation of this authorization shall be effective to prevent disclosure of records and communications until it is received by the person otherwise authorized to disclose records and communications
I have a right to receive a copy of this authorization.