I hereby authorize Variety the Children’s Charity of St. Louis (“Variety”) to use and/or disclose protected health information and personally identifiable information about me as described below (“PHI”) to our funding partners, which may include, but are not limited to: Productive Living Board for St. Louis County Citizens with Developmental Disabilities, St. Louis Office for Developmental Disability Resources, Developmental Disabilities Resource Board of St. Charles County, Developmental Disabilities Advocates (“Funding Partners”) for the purposes of verifying the participant’s eligibility to receive funding assistance utilizing the Funding Partners’ online portal(s) and billing.
I further authorize Variety to use and/or disclose PHI to similarly situated charities, which may include, but are not limited to: UCP Heartland and Rise Services, Inc, as well as relevant equipment vendors, for the purpose of providing and coordinating the participant’s receipt of Eastern Region Alliance funded items and services.
The PHI that may be used and/or disclosed is: Participant’s Name, Date of Birth, Address, Telephone Number, Social Security Number, Missouri Department of Mental Health Division of Developmental Disabilities ID, Race, and Diagnosis, Type of Adaptive Equipment, and/or other applicable health information to confirm medical necessity, administer the service, and bill funders.
I understand that this authorization shall remain in effect until the conclusion of my involvement with Variety’s Equipment and/or Therapy programs.
Neither Variety, nor any of the Funding Partners, will receive direct or indirect remuneration in exchange for disclosing the PHI. I understand that my eligibility to receive assistance from the Funding Partners and Variety may be conditioned on whether I sign this form, as my refusal may limit Variety’s ability to share PHI with Funding Partners, which is necessary to determine eligibility for funding. I understand that I have the right to revoke this authorization, in writing, at any time, except to the extent that Variety has acted in reliance upon it, by sending written notification to:
Christina Altholz, Privacy Officer
Variety the Children’s Charity of St. Louis
11840 Westline Industrial Drive Suite 220
St. Louis, MO 63146
I understand I have the right to refuse to sign this authorization. I understand that PHI used or disclosed pursuant to this authorization may be redisclosed by the recipient and its confidentiality may no longer be protected by federal or state law.
This form is only required for residents of St. Louis City, St. Louis County, St. Charles County, and Jefferson County. If you do not live in one of those areas, please disregard this form.
