CONSENT AUTHORIZATION FORM 同意授权书

Association of Chinese Americans 密西根美华协会 (ACA)
Detroit Area Agency on Aging 底特律地区老年局(DAAA)
Detroit Wayne Integrated Health Network 底特律·韦恩综合医疗网络 (DWIHN)
Eastern Michigan University- Center for Health Disparities Innovations and Studies 东密西根大

学健康差异创新与研究中心 (EMU- CHDIS)

National Coalition for Asian Pacific American Community Development 亚太裔美国人社区发展

全国联盟(National CAPACD)

Arab Community Center for Economic and Social Services 阿拉伯社区经济和社会服务中心

(ACCESS)

Michigan Health Endowment Fund 密西根健康捐赠基金 (MHEF)

The purpose of this Consent Authorization Form is to ensure that you are making an informed decision to provide your personal information to ACA, DAAA, DWIHN, EMU-CHDIS, National CAPACD, ACCESS & MHEF in order to provide you cultural & social services. 本同意书的目的是确保您做出知情同意的决定,将您的个人信息提供给密西根美华协会,底特律地区老年局,底特律·韦恩综合医疗网络,东密西根大学健康差异创新与研究中心,亚太裔美国人社区发展全国联盟和密西根健康捐赠基金,以便为您提供您所需要的文化和社会服务。
 

In this authorization form 在此授权书中:

  • Personally Identifiable Information 个人身份信息 (PII)
    Examples, but not limited to: name, phone #, email, home address, income & household size information.
    示例,但不限于:姓名,电话号码,电子邮件,家庭住址,收入和家庭人数信息。
  • The words “I”, “me”, or “my” include my authorized representative if I have one.
    如果有“我”或“我的”一词,则包括我的授权代表。

By signing this consent authorization form, I understand 通过签署此同意授权书,我了解:

  1. I don’t have to provide any information I don’t want to share. 我不必提供不想共享的任何信息。
  2. The ACA, DAAA, DWIHN, EMU-CHDIS, National CAPACD, ACCESS & MHEF are required to keep my PII private & secure when creating, collecting, disclosing, accessing, maintaining, storing, and/or using my PII. 创建,收集,披露,访问,维护,存储和/或使用我的PII时,要求密西根美华协会,底特律地区老年局,底特律·韦恩综合医疗网络,东密西根大学健康差异创新与研究中心,亚太裔美国人社区发展全国联盟和密西根健康捐赠基金保持我的PII隐私和安全。
  3. I can cancel my consent authorization at any time. 我可以随时取消我的同意授权。
  4. I have the right to participate in all of my service decisions. 我有权参与关于我的所有服务决定。
  5. I have the right to receive service in a manner that is non-coercive & protects my right to self-determination. 我有权以非强制性的方式获得服务并保护我的自决权。
  6. I have the right to request a review of my case record & service plan. 我有权要求审查我的案例记录和服务计划。
  7. I have the right to refuse any service or treatment unless mandated by law or court order. 除非法律或法院命令强制要求,否则我有权拒绝任何服务或治疗。
  8. I have the right to be informed about the consequences of such refusal. 我有权被告知这种拒绝的后果。

AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION

发布信息授权同意书

I understand that my personal and/or health information records are protected from disclosure under Federal and/or state law.  I may revoke this authorization at any time in which no information can be released except as authorized or allowed by law.  File copy is considered equivalent to the original.  我了解我的个人和/或健康信息记录收到联邦和/或州法律的保护，不得公开。我可以在任何时候撤销本授权，撤销后无权在任何时间公布任何我的个人信息，除非在法律允许或授权的范围内。文件副本被认为等同于原始文件。

I have received and understand 我已经收到并完全理解the Client Rights & Responsibilities客户的权利与责任；Client Grievance Policy 客户申诉政策；Behavior Support & Management Policy行为支持与管理政策 & Charges 收费标准等各项表格的具体内容。