CONSENT TO SHARE MY INFORMATION
Calendar Year 2015
CONSENT TO RELEASE MEDICAL INFORMATION
The purpose of this form is to gain your consent to share information that will improve coordination of your
HIV medical care between clinicians and medical case managers who provide services to you through the
Ryan White Program. The Ryan White Program pays for medical and support services related to your HIV
care. The decision to sign or not sign this form will not affect the HIV services you receive. You will still be
able to receive HIV services through the Ryan White Program if you do not sign this form but it may be more
difficult for your medical case manager to access your health care information, which may limit their ability to
help you meet your needs.
Background: As required by law, the Minnesota HIV/AIDS Surveillance System collects information on
everyone in Minnesota who has HIV/AIDS. CAREWare is a system that contains data about the services that
individuals who have HIV/AIDS are receiving through the Ryan White Program.
By signing this form, you authorize the Minnesota Department of Health (MDH) to release the following
information from your record in the Minnesota HIV/AIDS Surveillance System to the CAREWare system:
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Date of HIV diagnosis
Date of AIDS diagnosis
Current HIV status
Date(s) and result(s) of CD4 lymphocyte count and percent test(s)
Date(s) and result(s) of viral load (HIV RNA Quantitative) test(s)
Vital status (alive or deceased) and date of death once deceased
The above information will be released from the Minnesota HIV/AIDS Surveillance System into CAREWare
every three months, if it meets the following criteria:
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Your HIV diagnosis date falls between 1/1/1982 and 12/31/2019.
Your AIDS diagnosis date (if applicable) falls between 1/1/1982 and 12/31/2019.
Your current HIV status is associated with a diagnosis date occurring between 1/1/1982 and 12/31/2019.
Your CD4 tests were performed between 1/1/1982 and 12/31/2019.
Your viral load tests were performed between 1/1/1982 and 12/31/2019.
Your current vital statistics as reported between 1/1/1982 and 12/31/2019.
By signing this form, you are allowing the following people to have access to your current HIV status, HIV
diagnosis date, AIDS diagnosis date, current vital status, and date of death once the information is in
CAREWare:
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All providers from whom you receive Ryan White-funded services
Staff of the Minnesota Department of Human Services (DHS) and Hennepin County Human Services
and Public Health Department (HSPHD) who are responsible for administration of the Ryan White
Program
MDH as administrators of CAREWare
By signing this form, you authorize that the following people will have access to your CD4 and viral load test
results once they are in CAREWare:
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Ryan White-funded clinical providers (i.e., physicians, nurses, physician assistants, nurse
practitioners) from whom you receive clinical services
Ryan White-funded medical case managers from whom you receive case management services
Staff of DHS and HSPHD who are responsible for administration of the Ryan White Program.
MDH as administrators of CAREWare
All information released from the Minnesota HIV/AIDS Surveillance System is private and subject to state
and federal data practices laws.
Agency Submitting ROI:
CONSENT
Patient/Client Name
Date of Birth
Current Gender
I consent to the release of the information identified on page one of this form from my record in the Minnesota
HIV/AIDS Surveillance System to the CAREWare system. The identified information will be released if it
occurred from 1/1/1982 through December 31, 2019.
This consent is effective as of the date of my signature and will be valid through December 31, 2019.
I may withdraw my consent at any time by telling my provider or by writing to MDH at*:
Tina Klein
Minnesota Department of Health
STD, HIV and TB Section
625 Robert Street North
PO Box 64975
St Paul, MN 55164-0975
My withdrawal of consent does not apply to information that was shared before the withdrawal.
Patient/Client Signature
Date of Signature
December 31, 2019
Effective Date
End Date
*A form you can use to withdraw your consent is available at the following address:
http://www.health.state.mn.us/divs/idepc/diseases/hiv/careware/resources/surveillance.html
You can also send a letter to MDH in order to withdraw your consent, but please be sure to include your name,
current gender and date of birth.
The following is a description of the Minnesota HIV/AIDS Surveillance System and CAREWare:
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Minnesota HIV/AIDS Surveillance System
In Minnesota, physicians, health care facilities and medical laboratories are mandated by the Communicable Disease
Reporting Rule, (Minnesota Rules, Chapter 4605) to report data on people diagnosed with HIV/AIDS to MDH for the
public health purposes of tracking communicable diseases. Because this reporting is mandated, the patient’s consent is
not required. The data stored in in the surveillance system are considered private health data and must be handled as
required by the Minnesota Government Data Practices Act.
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CAREWare Client Level Data System (CAREWare)
The Health Resources Services Administration (HRSA) requires Ryan White-funded providers to report individual level
data for all clients who receive funded services, including demographics, HIV status, income, and specifics of services
received (client names are not reported to HRSA). In Minnesota, these data are stored in CAREWare. The data stored in
CAREWare are considered Protected Health Information and must be handled as required by HIPAA Privacy and
Security Rules. Ryan White-funded providers use individual level data to coordinate care for their clients. The funders of
Ryan White Program services in Minnesota (Hennepin County) and the Minnesota Department of Human Services
[DHS]) use the data to ensure access to and quality of Ryan White Program services.