Healthcare CDS Packet

HEALTHCARE CDS PACKET

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance Information

Medical History & Current Status

Please indicate chronic conditions by checking all that apply.

Diabetes    Hypertension    Heart disease

Asthma/COPD    Kidney disease    Mental health condition

Clinical Decision Support (CDS) Consent and Acknowledgment

Purpose: Clinical Decision Support (CDS) refers to electronic tools and algorithms used to assist clinicians in diagnosis, treatment selection, medication prescribing, and risk assessment. The CDS tools used by this provider will process clinical data from the patient record to generate informational recommendations to support clinical decision-making.

Data Use and Disclosure: I understand that my clinical information, including problem lists, medications, allergies, laboratory results, imaging reports, and encounter notes, may be processed by CDS software hosted within the health system or by a contracted CDS service to produce decision support output. I authorize the use of my clinical data for CDS purposes as described.

Benefits and Risks: CDS may improve the quality of healthcare by providing evidence-based recommendations, identifying potential medication interactions, and supporting preventive care. CDS outputs are informational only and do not replace clinician judgment. Risks include potential inaccuracies in automated recommendations, incomplete data inputs, and the possibility of recommendations that are not appropriate for my specific clinical situation.

Consent: By checking the box below I authorize the use of my health information for CDS as described, and acknowledge that clinicians may rely on CDS output in formulating clinical plans. I understand I may decline or withdraw this authorization at any time by providing a written notice to the clinic; withdrawal will not affect actions already taken in reliance on this consent.

I consent to the use of my clinical information for Clinical Decision Support purposes.

Data Sharing & Third-Party Services

Some CDS services may be provided by third-party vendors under contract with this health system. I authorize disclosure of the minimum necessary health information to contracted CDS vendors for the purpose of generating clinical decision support. Such vendors are contractually obligated to protect my information consistent with applicable privacy laws.

I authorize the disclosure of my protected health information to contracted CDS vendors as necessary for CDS services.

HIPAA Acknowledgment & Authorization for Release

I acknowledge that I have been made aware of the provider's Notice of Privacy Practices explaining how my medical information may be used and disclosed. I authorize the release of my medical information as necessary for treatment, payment, healthcare operations, and the CDS uses described above.

Revocation: I may revoke this authorization at any time by delivering a written notice to the health record custodian except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect disclosures already made in reliance on this authorization prior to receipt of the revocation.

Patient Certifications

By signing below I certify that the information provided on this packet is true and accurate to the best of my knowledge. I have read and understand the CDS consent, data sharing provisions, and HIPAA acknowledgement contained in this packet. I understand that CDS outputs are advisory, and that my clinician retains independent judgment over any clinical decisions.

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