INDIVIDUAL AUTHORIZATION FOR RELEASE OF INFORMATION
We understand that information about you and your health is personal and we are committed to protecting the privacy of that information. Because of this commitment, we must obtain your written authorization before we may use or disclose your protected health information for the purposes described below. This form provides that authorization and helps us make sure that you are properly informed of how this information will be used or disclosed. Please read the information below carefully before agreeing to the terms of this authorization.
USE AND DISCLOSURE COVERED BY THIS AUTHORIZATION
Who will use and disclose my information? Prairie Cardiovascular, Prairie Heart Institute at HSHS St. John’s Hospital or any other Prairie Heart Institute of Illinois facility (“Prairie”) will disclose the information you submit about your experience by electronically posting it to www.prairieheart.org and/or any other Prairie social media channels. Prairie will send you messages regarding the status of your submission through the email service Physician and APC of Prairie’s choosing. Prairie may use the information you submit to contact you to request permission to use the information you submit about your experience for other purposes. Prairie may also use the information you submit about your experience for: (i) educational, training, and/or promotional purposes at Prairie and/or at any other location(s); (ii) publicity, advertising (print, digital, and/or television), publications, and/or solicitation of contributions; and/or (iii) broadcast and/or other public display or viewing.
Who will see my information? Anyone visiting www.prairieheart.org and/or any Prairie social media channels may see or use the information you submit. Administrators of the email service Physician and APC Prairie uses to send you status messages will also have access to limited information, primarily your email address. In addition, in the event Prairie uses your information as described above members of the general public will see the information.
What information will be used or disclosed? The information used and disclosed will be limited to the information you submit through this website.
The information posted/disclosed on www.thedoctorsofprairie.com, and/or Prairie’s social media channels, or otherwise used and/or disclosed as described above, may include:
- your name
- the city/town, state/province/territory, and country where you live;
- the story of your care at Prairie with information on your condition/injury, diagnosis, and treatment (including surgery if applicable);
- the name of your Prairie physician(s), therapist(s) and other caregivers; and your photo and/or video.
The information disclosed to Prairie’s email Service Physician and APC, and used by Prairie to contact you, will include your:
If you submit sensitive information, that information may be deleted from your submission prior to your story being posted to www.thedoctorsofprairie.com and/or Prairie's social media channels, or if the sensitive information cannot be deleted from your submission without compromising the integrity of your story, we may decline to post your submission altogether. The following types of information are considered sensitive and will not be posted/disclosed:
- HIV-related information (which is any information indicating that you have had an HIV-related test, or have HIV infection, HIV-related illness or AIDS, or any information that could indication you have been potentially exposed to HIV);
- Substance abuse information;
- Psychiatric/psychotherapy care information;
- Sexually transmitted disease information;
- Tuberculosis information; and
- Genetic information.
What is the purpose of the use or disclosure? The purpose of the use or disclosure is to share your experience.
When will this authorization expire? This authorization will expire 15 years from the date you submit it to Prairie. After the expiration of this authorization, Prairie will not use or disclose your health information for the purposes described herein, unless you authorize such additional use or disclosure by submitting another authorization.
By agreeing to the terms of this authorization, you authorize the use or disclosure of your protected health information, as described above. This information may be re-disclosed if the recipient(s) described in this authorization is not required by law to protect the privacy of the information, and such information is no longer protected by federal health information privacy regulations.
You have a right to refuse to agree to the terms of this authorization. Your health care, the payment for your health care, and your health care benefits will not be affected if you do not agree to the terms of this authorization, but we will not be permitted to disclose your information as described on this authorization without your agreement.
You have a right to receive a copy of this authorization after you have agreed to its terms. If you would like a copy of this authorization, please send your request to: Prairie Heart Institute of Illinois, 619 E. Mason St., Suite 3P10, Springfield, IL 62701.
If you agree to the terms of this authorization, you will have the right to revoke it at any time, except to the extent that Prairie has already taken action based upon your authorization. To revoke this authorization, please write to Prairie Heart Institute of Illinois, 619 E. Mason St., Suite 3P10, Springfield, IL 62701.
Unless you represent below that you are the personal representative of an adult or minor patient, Prairie will only post information about you. If you submit information about another patient or individual that could be considered protected health information, that information will be deleted from you submission prior to your story being posted to www.thedoctorsofprairie.com and/or Prairie’s social media channels, or if the information cannot be deleted from your submission without compromising the integrity of your story, Prairie may decline to post your submission altogether.