Healthcare ACO Documents

HEALTHCARE ACO PARTICIPATION & AUTHORIZATION

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ACO Participation and Data Sharing Authorization

Definitions: For purposes of this document, "ACO" means the Accountable Care Organization responsible for coordinated care and quality measurement for participating patients. "Protected Health Information" or "PHI" means individually identifiable health information maintained by any provider, payer, or the ACO.

Participation: I voluntarily consent to assignment to the ACO for purposes of care coordination, quality reporting, population health management, payment reconciliation, and related health care operations. I understand that participation may involve the ACO's access to portions of my medical records from participating providers and payers.

Authorization to Use and Disclose PHI: I authorize any treating health care provider, health plan, payer, and their agents to disclose my PHI, including but not limited to medical records, claims information, laboratory and imaging results, medication history, and utilization data, to the ACO and its authorized delegates and contractors as necessary to carry out care coordination, quality measurement, utilization review, payment activities, and other health care operations permitted by law.

Redisclosure: I understand that once my PHI is disclosed to the ACO or its delegates, it may be further disclosed as permitted by law and that such redisclosure may no longer be protected by state or federal privacy laws to the same extent. The ACO will use reasonable safeguards and only permit disclosures consistent with applicable law.

HIPAA Acknowledgment

I acknowledge that I have been offered a copy of relevant privacy practices and notices describing how my health information may be used and disclosed, and my rights under federal privacy rules. Acceptance or acknowledgment of privacy information does not affect my right to revoke this authorization as provided below.

Authorization Term, Revocation, and Miscellaneous

Term and Expiration: This authorization shall remain in effect until the earlier of the date specified by me below or my written revocation as described herein. If no expiration date is provided, this authorization will expire three years from the date of my signature, unless otherwise prohibited by law.

Revocation: I may revoke this authorization at any time by providing a signed, written notice to my primary care provider or the ACO’s designated privacy officer. Revocation is effective upon receipt but will not affect disclosures made in reliance on this authorization prior to receipt of the revocation.

Conditions and Rights: I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing this authorization, except where permitted by law. I understand that I have the right to receive a copy of this authorization upon request.

Liability and Compliance: The ACO and participating providers will comply with applicable state and federal law governing use and disclosure of PHI. Neither the ACO nor participating providers shall be liable for uses of information disclosed in accordance with this authorization and applicable law.

Patient Certification

By signing below I certify that I am the patient or I am the patient’s legally authorized representative, that I have read and understand this authorization, that the information provided on this form is true and correct to the best of my knowledge, and that I voluntarily authorize the uses and disclosures described above.

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