Healthcare AHP Form

HEALTHCARE AHP FORM

This form documents patient demographic and health information and provides limited authorization and acknowledgements required for enrollment in the Accountable Health Program (AHP). Completion of this form authorizes the exchange of protected health information as described below and records the patient’s consent for participation in AHP services. All information provided will be used for treatment, payment and health care operations as permitted by law.

Patient Information

Emergency Contact

Insurance Information

Medical History & Current Health Status

Chronic Conditions (check all that apply): Diabetes Hypertension Heart disease Asthma/COPD None of the above Other

Tobacco or nicotine use: Yes No     Pregnant or possibly pregnant: Yes No

Program Enrollment Details

Primary treating provider or clinic:

Authorization to Use and Disclose Protected Health Information

I authorize the release of my protected health information (PHI) as necessary for enrollment, care coordination, treatment, payment, and program evaluation between:

The types of information to be disclosed include (check all authorized):
Medical records, progress notes, diagnoses and treatment plans
Laboratory results and reports
Imaging reports (X-ray, MRI, CT)
Mental health records (psychotherapy notes excluded unless specifically indicated below) Authorize release of mental health records
Substance abuse treatment records Authorize release of substance abuse records
HIV-related information Authorize release of HIV-related information

Purpose of disclosure:

This authorization expires on: . If no date is provided, authorization automatically expires twelve months from the date of signature below.

I understand that I may revoke this authorization at any time by submitting a written revocation to the disclosing provider or recipient, except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect disclosures made in reliance on this authorization prior to receipt of the revocation.

I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations. If I authorize disclosure of substance abuse treatment records, mental health records or HIV-related information, I acknowledge that such information is subject to additional protections and will be disclosed only if I specifically authorize their release above.

Acknowledgements and Consent

By signing below I acknowledge and agree to the following:

1. I consent to enrollment in the Accountable Health Program and to the exchange of my health information as specified in this form.
2. I understand participation in AHP services is voluntary and I may withdraw consent at any time by written notice.
3. I have been informed of potential benefits (improved coordination, tailored care plans) and potential risks (disclosure of sensitive health information to authorized recipients, loss of confidentiality through redisclosure).
4. I acknowledge that I have been offered the facility's privacy practices and that I understand my rights regarding release of medical information.

Consent for routine program communications (telephone, text, email): I consent to receive communications regarding appointments, care coordination and program activities.

Additional Authorizations & Notices

If the patient is a minor or is signing by a legal guardian or health care proxy, complete the Relationship field in the signature block and provide documentation of authority upon request.

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