AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION
Thank you for participating in the Family Caregivers Center Online Community website (the "Site"). Because the Site is intended to be a communal place for family caregivers to find support from and networking opportunities with other caregivers and access information and resources to assist with being a caregiver, information posted on the Site will be publicly available. Please carefully review this Authorization for Release of Health Information.
I understand that the Site is an online, public community and I am responsible for determining how much personal information I wish to post. I further understand that the Site is not a medical provider and does not provide medical advice. I acknowledge and agree that I should take care to avoid posting information related to my or anyone else's health. In the event any of the information I post contains information that is, or could be considered, Protected Health Information, I hereby authorize Mercycare Service Corporation and its affiliates to disclose that information to the Site, to all other registered Site users, and to anyone who may access the Site. I specifically authorize the release and inclusion of any information I post that contains information related to acquired immunologic syndrome (AIDS) or human immunodeficiency virus (HIV), alcohol and drug abuse treatment, and/or behavioral or mental health services.
I understand that I may revoke this authorization at any time by sending a written notice to Mercy's Health Information (Medical Records) department. My cancellation will take effect when the written notice is received and it will not apply to information that has already been released in response to this Authorization. I understand that revocation of the Authorization will result in discontinuance of my use of the Site. This Authorization will automatically expire when the Site is discontinued and no longer in use.
I understand that authorizing the disclosure of this health information and use of the Site is voluntary. I need not sign this form in order to receive medical treatment from Mercycare Services Corporation or its affiliates or services from the Family Caregivers Center. I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information may be redisclosed and no longer protected by federal privacy regulations unless otherwise prohibited from redisclosure under other federal and/or state laws or regulations.
I authorize the release of my Protected Health Information as described above.
(Last revised 11/22/24)