HIPAA Agreement

Authorization for Love, Chloe Foundation to Release Patient Information

By submission of the above application, I authorize Love, Chloe Foundation and Monkey In My Chair and its employees and representatives to disclose the following protected health information concerning my child to the trustees, officers, volunteers, employees or agents of my child’s respective school and treating hospital or medical professional. I hereby release such entities to disclose information considering my applicability to the Monkey In My Chair program for the purposes of determining eligibility according to the program’s requirements.

• Patient information such as name, gender, date of birth, address;
• Family information such as names of parents/caretakers, addresses of parents/caretakers, phone numbers and email addresses of parents/caretakers;
• Treatment information and status;
• Diagnosis; and
• General and emotional well-being.

I understand that I have the right to revoke this Authorization at any time by delivering a written revocation to Love, Chloe Foundation except that such revocation shall not be effective to the extent that action has been taken in reliance on this Authorization or prior to its receipt.

This Authorization does not have an expiration date and shall expire only in the event I revoke this Authorization. I understand that with this Authorization, the above information is not covered by the federal privacy regulations and such information may not longer be protected by HIPAA.