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Patient and Family Engagement Community – Partner Sign Up

General Info
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Which best identifies you?

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Race/Ethnicity




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Department(s)/Division(s) where You / Patient/Champion has been seen



















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How would you like to get involved?
Miscellaneous
How did you hear about these opportunities to get involved?



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CCHMC may use/disclose the following health information about the individual (Select all that apply)




CCHMC may use/disclose this health information for the purposes described below (Select all that apply)




By signing below, I authorize CCHMC to use and/or disclose the health information specified in this authorization and confirm to the best of my knowledge that I am legally authorized to represent the interests of this individual.

• CCHMC will not condition treatment, payment, enrollment, or eligibility for benefits on this signed authorization.

• The health information used and/or disclosed as a result of this authorization may be subject to redisclosure by the person or entity receiving such information. At that point, it is no longer protected by the federal privacy regulations. CCHMC is not responsible for the use of information, in whole or in part, by third parties.

• Any photos, images, or other representations specified above become the property of CCHMC or its representatives.

• This authorization is given without promise of compensation. The parent/legal guardian and the individual release to CCHMC any right, title and/or interest of any kind they may have in the information or images produced.

As stated in the Notice of Privacy Practices, I understand that I may withdraw this authorization at any time. Notification of withdrawal must be done in writing and sent to the CCHMC Health Information Management (HIM) Department, 3333 Burnet Avenue, ML 5015, Cincinnati, OH 45229. This authorization will not be withdrawn or expire for situations where CCHMC has already taken action as described in this authorization. This authorization will only expire if revoked by me in writing as stated above.

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This form must be signed and dated to be valid. If the individual is an emancipated minor or 18 years of age or older, s/he is required to sign the authorization.
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