Healthcare Care Coordination Notice

HEALTHCARE CARE COORDINATION NOTICE

Patient Name:    Date of Birth:

Patient Information

Male   Female   Other   If Other, specify:

Insurance Information

Medical History (Relevant to Coordination)

Notice of Care Coordination

Purpose: This Notice explains that members of your care team may share protected health information with one another and with other authorized entities for the purposes of coordinating your care, managing transitions between care settings, arranging community supports, scheduling, and obtaining payment for services. The legal basis for these disclosures includes treatment, payment, and health care operations.

Types of Information That May Be Shared: Information that may be shared for care coordination includes but is not limited to problem lists, diagnoses, medication lists, allergies, laboratory and imaging results, care plans, discharge summaries, and billing/insurance information.

Parties Authorized to Receive Information: The following entities may be involved in care coordination and may receive the information described above: treating clinicians, primary care providers, specialists, behavioral health providers, nurses, case managers, social workers, care coordination organizations, community-based service providers, and payers/insurers as necessary to arrange or pay for care.

Benefits & Risks: Coordinating health information among providers may improve continuity of care, reduce duplicated services, and improve outcomes. Potential risks include the possibility that protected health information may be disclosed to individuals or organizations outside your direct care team. All disclosures will be limited to the minimum necessary information to accomplish the care coordination purpose.

Right to Refuse or Revoke: You have the right to refuse or revoke consent to care coordination at any time. To revoke this authorization, you must submit a dated, written statement to the facility or clinician listed below. Revocation does not apply to disclosures already made in reliance on your prior consent and does not affect treatment, payment, enrollment, or eligibility for benefits that occurred before the revocation.

Expiration: Unless revoked earlier, this authorization/notice will expire on the date entered below or, if no date is entered, one year from the date of signature.

Consent Options (Check applicable box)

I consent to the sharing of my protected health information for care coordination as described in this Notice. I consent to the sharing of relevant information with family members or friends involved in my care. I consent to the sharing of information with community-based organizations or social service agencies for care coordination and support services. I consent to the sharing of information with my insurer or payer when necessary for payment and care coordination. I decline care coordination disclosures (opt-out). I understand that declining may limit coordinated supports offered on my behalf.

Patient Acknowledgement

By signing below, I acknowledge that I have read and understand this Care Coordination Notice. I understand what types of information may be shared, who may receive the information, and my rights to refuse or revoke consent. I understand that my signature is my authorization for the disclosures described above unless I have specifically declined.

Contact for Questions or Revocation: Contact Name:    Phone:

Sign Now