Record Use and Record Release Consent

I hereby authorize Care Resource to retain, preserve and/or use my HIV testing and counseling record for coordination of my referrals to other services, linkage to and coordination of medical care, coordination of partner notification with the department of Health, scientific research, healthcare operations, or teaching purposes.

I hereby grant access to my medical records to the senior management of Care Resource for the specific purpose of evaluating the ongoing quality of care rendered by their staff. I further authorize the senior management of Care Resource to use portions of my HIV testing record as necessary for the purposes of educating or disciplining their staff, provided that the records will not be identified as pertaining to me specifically without my expressed permission.

I voluntarily authorize, give my permission and consent to the release of all my HIV testing and counseling information and records to other institutions, agencies, health care organizations or healthcare providers who accept me for medical or institutional care. I understand that my HIV testing and counseling information may relate to such sensitive health conditions, including, but not limited to records which may indicate the presence of a communicable disease or non-communicable disease; and tests for or records of HIV/AIDS or sexually transmitted diseases.

I understand that the purpose of my voluntary authorization and consent to allow use and disclosure of all my HIV testing and counseling information is for the purpose of linking me to essential prevention services, medical care, social or behavioral health services as appropriate and as I am eligible for.

I understand that refusing to consent to the Record Use and Release Consent while still doing the test does not stop disclosure of my health information that is otherwise permitted by Law without my specific authorization or permission (384.25).

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