Authorization for Access to Patient Information

Through a Health Information Exchange Organization

I request that health information regarding my care and treatment be accessed as set forth on this form. I can choose whether or not to allow Journey Clinical Psychiatry, P.C., Journey Clinical Psychiatry CA, PC and Journey Clinical Psychiatry, TX, PLLC (collectively, “Journey”) to obtain access to my medical records through a health information exchange (“HIE”).  If I give consent, my medical records from the facilities and clinicians that provide me care can be accessed using the HIE.  The HIE shares health information electronically to improve the quality of health care.  

The choice I make in this form will NOT affect my ability to receive medical care. The choice I make in this form does NOT allow health insurers to have access to my information for the purpose of deciding whether to provide me with health insurance coverage or pay my medical bills.

My questions about this form have been answered and I have been provided a copy of this form.

Details about the information accessed through a HIE and the consent process:

1. How Your Information May be Used. Your electronic health information will be used only for the following healthcare services:

  • Treatment Services. Provide you with medical treatment and related services.
  • Insurance Eligibility Verification. Check whether you have health insurance and what it covers.
  • Care Management Activities. These include assisting you in obtaining appropriate medical care, improving the quality of services provided to you, coordinating the provision of multiple health care services provided to you, or supporting you in following a plan of medical care.
  • Quality Improvement Activities. Evaluate and improve the quality of medical care provided to you and all patients.

2. What Types of Information about You Are Included. If you give consent, Journey may access ALL of your electronic health information available through a HIE in which it participates. This includes information created before and after the date this form is signed. Your health records may include a history of illnesses or injuries you have had (like diabetes or a broken bone), test results (like X-rays or blood tests), and lists of medicines you have taken. This information may include sensitive health conditions, including but not limited to:

  • Alcohol or drug use problems
  • Birth control and abortion (family planning)
  • Genetic (inherited)
  • diseases or tests
  • HIV/AIDS
  • Mental health conditions
  • Sexually transmitted diseases
  • Medication and Dosages
  • Diagnostic Information
  • Allergies
  • Substance use history summaries
  • Clinical notes
  • Discharge summary
  • Employment Information
  • Living Situation
  • Social Supports
  • Claims Encounter Data
  • Lab Tests

3. Where Health Information About You Comes From.  Information about you comes from places that have provided you with medical care or health insurance. These may include hospitals, physicians, pharmacies, clinical laboratories, health insurers, the Medicaid program, and other organizations that exchange health information electronically.  

4. Who May Access Information About You, If You Give Consent.  Only health care providers permitted by law and by the HIE to access information may access your information through the HIE.

5. Public Health and Organ Procurement Organization Access. Federal, state or local public health agencies and certain organ procurement organizations are authorized by law to access health information without a patient’s consent for certain public health and organ transplant purposes.  These entities may access your information through an HIE for these purposes without regard to whether you give consent, deny consent or do not fill out a consent form.

6. Penalties for Improper Access to or Use of Your Information.  There are penalties for inappropriate access to or use or your electronic health information.  If at any time you suspect that someone who should not have seen or received access to your information has done so, you may file a complaint with the Office for Civil Rights at http://www.hhs.gov/ocr/privacy/hipaa/complaints/. 

7. Re-disclosure of Information. Any organization(s) you have given consent to access health information about you may re-disclose your health information, but only to the extent permitted by state and federal laws and regulations. Alcohol/drug treatment-related information or confidential HIV-related information may only be accessed and may only be re-disclosed if accompanied by the required statements regarding prohibition of re-disclosure.

8. Effective Period. This consent form will remain in effect until the day you change your consent choice, in case of a minor until he/she turns 18 years of age, or until 50 years after your death.

9. Changing Your Consent Choice. You can change your consent choice at any time by submitting a new consent form with your new choice. Organizations that access your health information through an HIE while your consent is in are not required to return your information or remove it from their records if you later revoke this consent.

10. Copy of Form. You are entitled to get a copy of this consent form.