Authorization Form Policy

Effective date of policy: April 14, 2003

Protected health information (PHI) will only be released from PRC with a properly executed authorization from the patient or his/her personal representative, except for treatment, payment, or health care operations (TPO) and as otherwise required by law. Examples of some instances in which we are required to disclose your PHI include: Public health activities; information regarding victims of abuse, neglect, or domestic violence; health oversight activities; judicial and administrative proceedings; law enforcement purposes; national security and intelligence; correctional institutions; and Worker's Compensation.

PRC will only use or disclose PHI, except as noted above, consistent with the terms of the authorization.

You may revoke your authorization to use or disclose PHI at any time but actions taken prior to the revocation are excluded. If authorization is a condition of obtaining insurance coverage, and the authorization is revoked, the insurer may contest a claim under the policy.

Authorizations must be properly executed by you or your personal representative. It should include, the date signed, specific PHI to be released or used, to whom this use or release relates, and an expiration date for the authorization.