Patient Medical Consent Form

AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION

To use and disclose a copy of the specific health information described below regarding:

✓ History and physical examinations
✓ Consultation reports
✓ Laboratory reports
✓ Operative reports
✓ Discharge summary
✓ X-ray/Diagnostic images
✓ Other, specify below.

To: CSTAR International,
Attn: CSTAR Cares Management Team,
14 Harwood Court, Suite 415
Scarsdale, NY 10583  USA
Phone (914) 340-1155

For the purpose of CSTAR International and CSTAR Cares Coordination

If the information to be disclosed contains any of the types of records or information listed below, additional laws relating to the use and disclosure of the information may apply. I understand and agree that this information will be disclosed only if I place my INITIALS in the applicable space next to the type of information.

This authorization is voluntary, and you may refuse to sign this authorization. Refusal to sign this authorization will affect your ability to participate in this care coordination program and failure to disclose any of the preceding conditions may result in surgery cancellation.

You may revoke this authorization in writing at any time. If you revoke your authorization, the information described above may no longer be used or disclosed for the purposes described in this written authorization. Any uses or disclosures already made with your permission cannot be undone.
I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure and no longer be protected under federal law. However, I also understand that federal or state law may restrict the re-disclosure of HIV/AIDS information, mental health information, drug/alcohol diagnosis, treatment, or referral information.

I understand that my health information may be shared with health care providers, nurse case managers, health lawyers, and other professionals who have been are currently, or will be involved in my care in order to better coordinate my care.

I have read this authorization and I understand it. Unless revoked, this authorization does not expire.

Signature is required.
Signature of individual or Legally Authorized Representative
Please put the date you sign the agreement