@extends('layouts.pdf') @section('content')
First Name | {{$patient->fname}} |
Last Name | {{$patient->lname}} |
DOB | {{$patient->DOB}} |
Gender | {{$patient->sex}} |
{{$patient->email}} | |
Phone Number | {{$patient->contact_no}} |
Address | {{$patient->street}} |
City | {{$patient->city}} |
State | {{$patient->state}} |
Zip Code | {{$patient->postal_code}} |
The BrazCo Resource Network (“Network”) is a coalition of community organizations in Brazoria and surrounding counties in Texas working together to provide community, health, and supportive services (“Services”) to individuals in the community. Organizations participating in the Network include food banks, transportation service providers, respite care providers, health care providers, philanthropic organizations and schools, and entities that assist with housing, utility and other basic needs.
The purpose of the Network is to refer you to organizations to assist you with your health care and basic needs. With your permission, community organizations can work together to collaborate and record the things you may need, such as food, nutritional care, clothing, housing assistance, job training, respite care, service coordination, and access to care. Staff and volunteers at the various organizations will want to reach out to you to coordinate services for you. This is why we are asking for your permission to share your Protected Information within the Network (“Purpose”). Protected Information is shared electronically among your Team on CHN MSSTM, a cloud-based data sharing platform hosted by CHN MSS.
Certain federal and state laws exist to protect you and your information. This “Protected Information” includes records in the following Categories (“Categories”):
These laws require your permission to use and disclose your Protected Information to improve the Services offered in support of your Basic Needs. Therefore, the Network and CHN MSS must have your express permission to share your Protected Information within the Network. By completing and signing this form, you are giving your permission. You can of course continue to seek services from organizations that participate in the Network, even if you do not give permission to share your Protected Information, but you will not be able to use the Network to receive those services. Your treatment, receipt of Services, payment, enrollment, or eligibility for benefits are not conditioned in any way on your signing this form.
Who could use or disclose my Protected Information if I’ve granted permission?Community organizations on the Network hosted by CHN MSS that are actively providing Services to or in support of your Basic Needs.
If I grant permission, for how long will my Authorization be valid?Your Authorization will be valid for ten (10) years, unless you exercise your right to revoke it sooner, as described below, or turn eighteen (18).
What are my rights once I have granted permission?I hereby authorize and grant permission to the BrazCo Resource Network, to use and disclose my Protected Information to other organizations on the Network for the Purpose. I understand that my care team includes organizations that participate in the Network. These organizations may include my educators; my past, current, and future treating providers; and law enforcement who provide emergency response service. I understand that by signing below, I am separately consenting to the sharing of Protected Information from each Category, if such information exists.
By signing below, I acknowledge that I have read and that I understand this Authorization form, and my rights with respect to my Protected Information. I also acknowledge a copy of this Authorization form is available upon request.
Signed: | {{$patauth->signed}} |
Printed name: | {{$patauth->printed_name}} |
Date: | {{$patauth->date}} |
Self: | {{$patauth->self}} |
Parent / Guardian of Minor Child (Under 18): | {{$patauth->parent}} |
Guardian / Conservator of Adult Client: | {{$patauth->guardian}} |