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DocuSign Envelope ID: D6EB45D6-6C12-4C2B-895B-067AF17D828F <br /> Master Data-Sharing Agreement <br /> Attachment F:Authorization Agreement for Disclosure and Sharing of Protected Health Information <br /> Orange County FSA Authorization Agreement for Disclosure and Sharing of Protected Health Information <br /> By signing this agreement,you give your authorization to disclose and share personally identifiable <br /> health information on the person listed below with authorized partners in the Orange County FSA.The <br /> purpose of sharing this information is to allow the Orange County FSA to provide well-informed, <br /> coordinated services to participants and their families,to conduct ongoing evaluation and improvement <br /> of programs to better serve the community, and to report results of programs and activities to <br /> residents, partners, and funders. <br /> The Orange County FSA takes every precaution to protect personal information from unauthorized use <br /> or release. Information obtained on persons shall not be published in a manner that will lead to the <br /> identification of any individual.This information is used solely for service provision and program <br /> evaluation purposes and identified information shall not be further re-disclosed to third parties not <br /> covered by this Consent Agreement without your prior written consent. I understand that the records to <br /> be disclosed and shared with Orange County FSA may include but are not limited to: <br /> Program sp from [health care provider names]: <br /> • Number and dates of health care visits <br /> • Immunization records <br /> • Blood screenings for lead levels <br /> • Body-mass index measures <br /> • Disability status <br /> • Chronic health conditions <br /> • Mental health status <br /> I consent to the disclosure of the personally identifiable information described above to the Orange <br /> County FSA entities and partners. <br /> Furthermore, I consent that the following parties may obtain the information described above stripped <br /> of any and all direct identifiers: <br /> • The U.S. Department of Education and its authorized contractor(s) <br /> For up-to-date information and questions, please go to <br /> http://www.orangecountync.gov/departments/health/FSA.php or contact the Orange County FSA data <br /> manager . Signing this agreement constitutes the granting of <br /> authorization for disclosure of protected health information under the Health Insurance Portability and <br /> Accountability Act (HIPAA). <br /> 19 <br />