Healthcare CCB Providers Form

Healthcare CCB Providers Form

Purpose: This form documents the patient authorization to disclose and exchange protected health information (PHI) among Community Care/CCB providers for the purposes of treatment, care coordination, and related administrative functions. Complete all applicable sections and sign at the end to authorize disclosure.

Patient Information

Date of Birth:    Gender:

Emergency Contact

Insurance / Payer Information

CCB Providers — Originating (Disclosing)

Provider / Organization Name:

CCB Providers — Receiving (Authorized to Receive)

Provider / Organization Name:

Purpose and Scope of Disclosure

I authorize exchange of the following information between the named CCB providers for the purposes indicated below (check all that apply):

Treatment / Care Coordination    Payment / Claims    Quality Improvement / Case Review    Referral / Transitional Care

Types of Information To Be Disclosed

Select the specific categories of PHI to be disclosed (check all that apply):

Entire Medical Record    Behavioral Health / Mental Health Records    Substance Use Disorder Records (special protections)    HIV/AIDS-related Information

Medication Records    Laboratory and Diagnostic Results    Claims and Billing Records    Other:

Duration and Expiration

This authorization is effective from: and expires on:

If no expiration date is provided, this authorization will expire one year from the effective date unless otherwise stated:

Rights, Revocation and Redisclosure

I understand that I may revoke this authorization at any time by providing a written notice of revocation to the disclosing provider or its medical records department. Revocation will not apply to information already released in reliance on this authorization, and will not affect actions taken prior to receipt of the revocation. To revoke, indicate revocation here:

I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected under federal privacy rules. Special federal protections apply to substance use disorder records and HIV-related information; these records may require additional written authorizations for redisclosure depending on applicable law.

Conditions of Authorization

I authorize the disclosing provider to use and disclose the information indicated on this form to the named recipient(s). I understand that signing this authorization is voluntary and that my refusal to sign will not affect my ability to obtain treatment, payment, enrollment, or eligibility for benefits, except where permitted by law. Where applicable, eligibility for certain services may be conditioned on disclosure to coordinate care; the provider will explain such conditions verbally prior to obtaining consent.

Patient Acknowledgement

By signing below, I acknowledge that I have read and understand this authorization, that the purpose and scope of the disclosure are described above, and that I have received a copy of this completed form upon request.

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