Healthcare Access Service Center Addendum

HEALTHCARE ACCESS SERVICE CENTER ADDENDUM

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Other

Emergency Contact

Insurance Information

Medical History (brief)

Addendum Details

This Addendum amends the existing Service Center Agreement between Healthcare Access Service Center and the above-named patient. Service Center Name: . Original Agreement Date: .

Effective Date of this Addendum: . Unless otherwise indicated, all terms of the original agreement remain in force except as explicitly modified herein.

Services and Access Authorized (select all that apply)

Case management and care coordination
Telehealth consultations and video visits
Access to electronic medical records and clinical summaries
Appointment scheduling and reminders
Transportation coordination to medical appointments
Billing and insurance information sharing for claim processing
Prescription refill requests and pharmacy coordination
Other:

Use, Disclosure and Limits

By signing this Addendum, the patient authorizes Healthcare Access Service Center to access, use, and disclose protected health information (PHI) as necessary to provide the services checked above. Permitted disclosures include communication with treating providers, insurance payors, pharmacies, and other service providers directly involved in the delivery of authorized services. This authorization does not permit disclosure of psychotherapy notes unless explicitly indicated in writing.

The Service Center shall limit disclosure to the minimum PHI necessary to accomplish the intended purpose. Redisclosure by recipients is prohibited unless permitted by law. The Service Center will implement reasonable administrative, technical, and physical safeguards to protect PHI in accordance with applicable law.

Expiration and Revocation

This authorization will expire on: . The patient may revoke this authorization at any time by delivering a written revocation signed by the patient or legal representative to the Service Center's records office. Revocation will not apply to disclosures already made in reliance on this authorization prior to receipt of the revocation.

Patient Rights and Certification

I understand that signing this Addendum is voluntary. I have the right to inspect or obtain copies of the PHI authorized for release. I understand that treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing this authorization unless such conditioning is expressly permitted by law and specifically stated here:

I certify that the information provided on this form is true and complete to the best of my knowledge, and I authorize the uses and disclosures described herein.

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