Page 34 - Privacy_Program

DP130A.12a (a) a description of the information to be used or disclosed that identifies the
information in a specific and meaningful fashion;

DP130A.12b (b) the name or other specific identification of the person(s), or class of persons,
authorized to make the requested use or disclosure;

P130A.12c (c) the name or other specific identification of the person(s), or class of
persons, to whom the organization may make the requested use or disclosure;
DP130A.12d (d) a description of each purpose of the requested use or disclosure;

DP130A.12e (e) an expiration date or an expiration event that relates to the participant or
the purpose of the use or disclosure;
DP130A.12f (f) a statement of the individual’s right to revoke the authorization in writing
and the exceptions to the right to revoke;

DP130A.12g (g) a description of how the participant may revoke the authorization;
DP130A.12h (h) a statement that the entity will not condition treatment, payment,
enrollment in a health plan, or eligibility for benefits on the provision of an
authorization, except as permitted by law.

DP130A.12i (i) a statement that information used or disclosed pursuant to the
authorization may be subject to re‐disclosure by the recipient and no longer be
protected.;

DP130.12j (j) the signature of the participant and date.

Employees with Access DP130A.13 If the authorization is signed by a personal representative of the participant,
to PRPI the authorization will contain a description of the representative’s authority to
act for the participant.

Employees with Access DP130A.14 The organization will provide the participant with a copy of the signed
to PRPI authorization.
Employees with Access DP130A.15 The organization will invalidate the authorization if:
to PRPI
DP130A.15a (a) any material information in the authorization is known by the organization
to be false;
DP130A.15b (b) the requirements of the authorization have not been filled out completely; or
DP130A.15c (c) the expiration date has passed or the expiration event is known by the
organization to have occurred.
Employees with Access DP130A.16 The organization will document and retain the signed authorization for a period
to PRPI of at least six years from the date of its creation or the date when it last was in
effect, whichever is later.
DP130A.17 Prior to use or disclosure of PRPI in marketing materials including the
organization’s website, print materials, proposals, speeches, and other media;
the organization will obtain authorization from the participant(s) whose
information will be used or disclosed using the organization’s Consent to use
Personal Images and Descriptions – Non‐Medical. See OR‐B‐402 – USE OF
PERSONAL IMAGES AND DESCRIPTIONS.

GES CONFIDENTIAL 31