Healthcare AHP Request

Healthcare AHP Request

Use this Healthcare AHP Request to designate an Authorized Health Professional (AHP) for purposes of treatment, care coordination, and limited access to protected health information. Complete all applicable sections, sign, and date at the end. Submission authorizes release of information consistent with the scope below and applicable law.

Patient Information

Patient Name:

Insurance Information

Medical History (relevant)

Authorized Health Professional (AHP) Details

AHP Name:

Scope of Authorization

Check all actions the AHP is authorized to perform with respect to the patient named above:

Provide direct treatment and medical care

Coordinate care and communicate with other health care providers

Access, receive, and review medical records (including imaging and laboratory results)

Access mental health and behavioral health records (where permitted by law)

Access substance use disorder treatment records (where permitted by law)

Receive billing and insurance information necessary for claims and payment

Other (specify):

Purpose and Duration

Purpose of this authorization (check all that apply):

Treatment / Care coordination

Insurance claim, payment, or benefits determination

Legal or administrative proceedings

Other:

Indefinite authorization until revoked in writing

Authorizations, Limitations and Notices

By signing below, I authorize the Providers and Agents of this organization to disclose, discuss and transmit my protected health information to the AHP and the AHP's authorized staff, only to the extent necessary to accomplish the purposes described above. This authorization includes verbal, written, and electronic communications unless expressly limited below.

I understand that information disclosed pursuant to this authorization may include information protected under federal or state law, including but not limited to mental health, substance use disorder treatment, HIV/AIDS-related information, and other sensitive records where permitted by law. I further understand that I may place specific limits on categories of information disclosed by describing such limits in the field below.

I understand that I may revoke this authorization at any time by providing a signed, dated written notice to the medical records department or by delivering written revocation to the AHP. Revocation will not affect disclosures already made in reliance on this authorization prior to receipt of the revocation.

I understand that the recipient of my health information may not be required to comply with federal privacy protections and that re-disclosure by the recipient may not be prohibited. I also understand that I may be charged a reasonable fee for copying and postage of medical records as permitted by law.

This authorization is not a condition of receiving treatment, payment, enrollment, or eligibility for benefits, unless the provision of such proof is necessary for the purpose stated above.

Acknowledgment of HIPAA / Privacy Notice

I acknowledge that I have been informed of my rights regarding my protected health information and have read or been offered the entity's Notice of Privacy Practices. I understand how the AHP may use and disclose my health information as authorized herein.

I acknowledge receipt of privacy information and consent to the uses described above.

Patient Certification

I certify that I am the patient named above or that I am authorized to act on behalf of the patient as the patient's legal representative. By signing below I authorize the release and disclosure of information as specified in this form. I affirm the information I have provided on this form is true and accurate to the best of my knowledge.

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