Healthcare Cerner Direct Form

Healthcare Cerner Direct Form

Purpose and Authorization

By signing this form I authorize the organization identified below to enroll me in Cerner Direct, a secure clinical messaging and health information exchange service, and to send, receive, access and store my protected health information for the purposes described herein. Organization Name:

Purpose of Exchange (check all that apply): Care coordination Transitions of care Clinical results / labs Referrals / consults

Patient Information

Patient Name:

Insurance / Subscriber

Medical History (brief)

Scope of Information to Be Exchanged

I authorize exchange of the following categories of information as needed to accomplish the stated purposes (check applicable categories):

Medication lists Allergies / adverse reactions

Laboratory and diagnostic results Problem list and diagnoses

Clinical notes (discharge summaries, history & physical, consults)

Exclusions and Sensitive Information

By initialing, I specifically authorize inclusion of the following sensitive categories if applicable. If left blank, these categories will be excluded from exchange unless required by law.

Technical and Security Terms

Cerner Direct uses secure, encrypted messaging for clinical exchange. I understand that electronic transmission may be interrupted or delayed and that the organization will use reasonable safeguards to protect my information. I acknowledge that participating entities may store messages in electronic health record systems and that access is governed by organizational policies and applicable law.

Authorization Period and Revocation

This authorization is effective on the date signed and will expire on:

I understand I may revoke this authorization at any time by submitting a written revocation to Organization Name: . Revocation will not apply to information already released in reliance on this authorization prior to receipt of the revocation.

Redisclosure and Consequences

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 law. I also understand that refusal to sign this form will not result in denial of treatment, payment, enrollment, or eligibility for benefits, except where the information is necessary for the provision of care.

HIPAA Acknowledgment

I have been provided the organization’s Notice of Privacy Practices describing how my health information may be used and disclosed, and my rights under HIPAA. I acknowledge receipt and that I understand my rights.

I acknowledge receipt of the Notice of Privacy Practices

Representative / Guardian

If signer is a legal representative, provide name and authority: Representative Name:

Attestation

I certify that I have read and understand this authorization, that the information I have provided is accurate to the best of my knowledge, and that I authorize the exchange of my protected health information as described above. I understand I may receive a copy of this authorization upon request.

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