I authorize University Hospitals and Rainbow Babies & Children’s Hospital to use the information that I share below regarding my experience in the Rainbow NICU to share with their online Web site audience. I understand that by selecting the I accept box, this allows University Hospitals to publish my NICU story on the www.rainbowbabies.org Web site, if it is selected. I understand that only my story and first and last name will be published on the Web site, if selected.
I understand that University Hospitals will NOT disclose information about me for any other purpose without my permission.
I understand that I may refuse to select this authorization and that treatment, payment, enrollment or eligibility for benefits will not be affected if I refuse to select this authorization.
I understand that I may revoke this authorization in writing at any time by submitting a written revocation letter to the UH Privacy Officer at UH Privacy Officer, Compliance and Ethics Department, 3605 Warrensville Center Road, Mail Stop # MSC 9105, Shaker Heights, OH 44122. I further understand that I cannot revoke this authorization to the extent that action has already been taken in reliance on this authorization.
I understand that the information described above may be redisclosed and may no longer by protected under the Health Insurance Portability and Accountability Act of 1996. However, if the above information included information from records whose confidentiality is protected by disclosure by Ohio and federal law (such as the release of HIV test results or diagnoses, substance abuse treatment records and psychiatric records), ORC Section 5122.31, 45 C.F.R. Part 2, and ORC Section 3701.243 prevent the recipients from making any further disclosure of it without the specific, written and informed release of the individual to whom it pertains, their authorized representative, or as otherwise permitted by law. A general authorization for release of information is not sufficient for this purpose.
By selecting the “I agree“ box, I understand that I am giving University Hospitals permission to publish my NICU story and my first and last name on the www.rainbowbabies.org Website, if my story is selected.
By selecting the “I agree“ box, I understand that I am giving University Hospitals permission to publish my NICU story and my first and last name on the www.rainbowbabies.org Website, if my story is selected.