I give my permission for the Team Gleason Foundation to share the information provided on the Team Gleason Application for Assistance and any documentation that I have attached to the application, to any organization that Team Gleason will contact to help me with my care, or to provide a service.
Section II- Effective Period
This authorization for release of information covers the period of health care all past, present, and future periods.
Section III- Extent of Authorization
By signing this document, I hereby authorize the release of my PHI (Protected Health Information) including medical records related to healthcare, or evaluations for DME (Durable Medical Equipment), and all information I have included on the Team Gleason Application for Assistance.
This medical information may be used by Team Gleason to contact DME manufacturers, wheelchair manufacturers, speech generating device manufacturers, any provider of the equipment and technology mentioned above, physicians, clinicians, physical therapists, occupational therapists, speech language pathologists, ALS clinic coordinators, or any other healthcare party on my behalf.
This authorization shall be in force and effect until 20 years from date of submission to Team Gleason, or until I expire.
I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining assistance from Team Gleason.
I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
Section IV- How Team Gleason May Use and Disclose Your PHI:
The following categories listed below describe different way that we use and disclose your PHI. We have provided you with examples in certain categories. Not every use or disclosure in a category will be listed.
Treatment. Team Gleason may use and/or disclose your PHI to provide the applicant with health care products or services, or to coordinate and/or help manage your health care with other providers. For example, we may disclose your PHI to a durable medical equipment provider, to have them schedule a time to show and demonstrate various products to the applicant such as different makes and models of power wheelchairs.
Payment. Team Gleason may use and/or disclose your PHI to a company to make a payment for services or equipment on your behalf. This may include information that identifies you, as well as your diagnosis and the products or services you have requested.
Operations. Team Gleason may use and/or disclose your PHI for administrative, operational, quality assurance, or other activities. For example, we may use your PHI to monitor the performance of the equipment and technology specialists who have provided service to you.
Business associates. We may allow business associates who provide services on Team Gleason’s behalf that involve the disclosure of your PHI. Our business associates will agree to take appropriate steps and necessary safeguards to properly protect your information.
Law Enforcement. We may disclose your PHI for law enforcement purposes if asked to do so by a law enforcement official.
Fundraising. We may contact you as part of a fundraising effort.
Threat Aversion. We may disclose your PHI when or if necessary to prevent a serious threat to your health and/or safety and/or that of another person.
Testimonials. We may disclose some of your PHI to create social media posts, include in printed material, electronic material such as emails, fundraising campaigns, or other uses related to the previously listed items.