SECTION 1: What information am I agreeing to share?

By signing below, I hereby authorize my Workit Health Clinic or agent, to use or disclose information contained in the medical and financial record of the patient identified above, which includes information that may be stored in a paper and/or other electronic format. Such notes may contain information on general medical care; substance use disorder treatment; psychological and social work counseling; human immunodeficiency virus (HIV) or acquired immune deficiency syndrome (AIDS), or AIDS-related complex including communicable diseases or infections, sexually transmitted diseases, venereal diseases, tuberculosis and hepatitis; demographic information; and information from other providers that are contained in the information maintained by my Workit Health Clinic. 

Use and Disclosure shall be limited to the following specific information contained in my records and/or obtained during the course of my diagnosis and treatment.

Please note that unless otherwise stated/specified, this release is valid for up to 1 year from signature date.

SECTION 3: Who do I want to share or disclose my information with?  

SECTION 4: Miscellaneous

If I fail to specify an expiration date or condition, this authorization is valid for the period of time lasting until I am discharged from my Workit Health Clinic or for up to one (1) year from the signature date, whichever is earlier. This authorization is subject to revocation at any time except to the extent my Workit Health Clinic who is to make the disclosure has already acted in reliance on it. Any revocation will be presented in writing to my Workit Health Clinic by notifying us by mail at Workit Health Clinic, Attn: Privacy Officer, 3300 Washtenaw Ave., Suite 280, Ann Arbor, MI 48104, United States, by telephone at 855-381-6234, or by email at hello@workithealth.com. My Workit Health Clinic will not condition my treatment, payment, enrollment, or eligibility for benefits on whether I provide this authorization. I understand that I am explicitly authorizing the disclosure of my Workit Health Clinic records and the re-disclosure of the other providers records. This authorization provides for a release of information about an individual whose confidentiality is protected by federal and state laws and regulation, including the Health Insurance Portability and Accountability Act of 1996 (45 C.F.R. §160-164) as well as 42 C.F.R part 2 and 42 U.S.C. §. §290dd-2, and state confidentiality laws. 42 CFR Part 2 (“Part 2”) prohibits unauthorized disclosure of any Part 2 records. No information disclosed from this authorization may be re-disclosed without the specific written consent of the individual about whom such information pertains.

The records used or disclosed pursuant to this authorization could be re-disclosed by the recipient. In this case, the records would no longer be protected by the substance use disorder patient records confidentiality law located at 42 CFR Part 2.

The patient's record (or information contained in the record) may be redisclosed in accordance with the permissions contained in the HIPAA regulations, except for uses and disclosures for civil, criminal, administrative, and legislative proceedings against the patient.

For members residing in the state of OKLAHOMA:
I understand that my clinical information and identity are specifically protected under Oklahoma Law at 43A O.S. § 1-109 and OAC 450:15-3-20.1. The information authorized for release may include records which may indicate the presence of a communicable or non-communicable disease. Under Oklahoma law (63 O.S. § 1-502.2), records concerning communicable or noncommunicable diseases are strictly confidential and are entirely exempt from the Oklahoma Open Records Act. These records will not be released to any party except under strict legal exceptions or with your specific, written consent.

SECTION 5: Signature

By signing below I acknowledge that I am aware of the confidential and/or privileged nature of the information being disclosed, and understand the benefits and/or disadvantages of disclosing such information. I hereby release my Workit Health Clinic, its affiliates and its agent and representatives, from all legal liabilities that may result from the release of this information according to this request..

By submitting, I agree that Workit Health will send information about this medical record request to me and to my designated recipient.

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