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Authorization to Use and Disclose Protected Health Information (or other confidential information)

The following Protected Health or other confidential information may be shared between one or more of the agencies/entities participating in Autism Lifeline Links for the purpose of providing services or referring you to the correct agency for which you are interested in receiving services.

Medical or Health Information (immunization records, assessments, diagnosis)
Psychological Reports (diagnosis)
Social History (Home Study)
Case Management Records (Assessment, Service Plan, Progress notes, correspondence)
ECI/School District information (Assessment, Service Plan, IEP, Autism Supplement, Behavior Improvement Plan)
Financial Information (tax return, pay stubs, SSI Letter, WIC, TANF, SNAP, child support)
Demographic Information
Other Information

I do authorize disclosure of such information electronically. If you choose not to disclose information, you will not be included in the ALL network of providers. You will still receive referrals to services but not within the connected system.

The information disclosed may be used by the individual/entity receiving the information for any and all services/participation in Autism Lifeline Links (ALL) for continuum of care. ALL is a network of providers caring for an individual with Autism utilizing a network system (TAV Connect) to ensure continuity of care and avoid duplication. TAVConnect is a HIPAA-secured, cloud-based platform meeting rigorous standards for data protection. Your personal information is gathered for demographic purposes only and will not be shared with any government agency. Your benefits will not be reduced due to sharing details related to your family with the ALL group.

Expiration Date: This authorization expires at the time Autism Lifeline LInks services are discontinued or upon my revocation.

This form was read by me or was read to me and I understand its purpose and content.

I do have an email addressI don't have an email address

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I am:

registering myself
(I am a person 18 years of age or older with Autism Spectrum Disorder).registering someone else
(I am the parent/guardian/caregiver of a person with Autism Spectrum Disorder ).

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