Healthcare CFASS Updated

HEALTHCARE CFASS UPDATED

Patient Information

Date of Birth:    Gender: Male Female Other

Emergency Contact

Insurance Information

Medical History

No known allergies:

Description of Services (CFASS)

I authorize Community-Provided Assistance and Support Services (CFASS) to provide the following services and interventions, including routine assistance, monitoring, and any specified clinical procedures described below. Specific services to be provided:

Risks, Benefits, and Alternatives

The undersigned acknowledges that the provider has explained the nature, expected benefits, and reasonably foreseeable risks of the proposed CFASS services. Benefits may include improved safety, stabilization of medical conditions, and enhanced independence. Risks may include adverse medication reactions, infection, skin breakdown, or need for emergency medical care. Reasonable alternatives, including refusal of specific services, have been explained.

I understand that I may refuse or withdraw consent at any time. Withdrawal of consent will be effective upon receipt of written notice by the CFASS program, and such withdrawal will not affect actions taken in reliance on this authorization prior to receipt of revocation.

Acknowledgement of explanation of risks and benefits:

HIPAA Authorization and Release of Information

I authorize the CFASS provider to use and disclose my protected health information to persons and agencies involved in my care or payment for care, including but not limited to family members, caregivers, emergency responders, and payors as necessary to coordinate services, as described below.

Purpose of disclosure:

I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken in reliance on it. I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations.

Patient Rights and Acknowledgement

By signing below, I certify that I have read and understand this authorization and consent form, that the information I have provided is true and accurate to the best of my knowledge, and that I have had the opportunity to ask questions and receive answers. I understand my rights regarding revocation, the ability to receive a copy of this authorization, and the limits of confidentiality described herein.

I acknowledge receipt of the provider's Notice of Privacy Practices and understand how my information may be used and disclosed in accordance with that notice:

Certification

I certify under penalty of law that the information provided on this form is true and complete. I authorize CFASS personnel to provide the services described and to take reasonable steps in an emergency, including arranging for transport to an appropriate facility. I agree that the CFASS provider may contact my listed emergency contact, health care providers, and insurers as necessary to provide care and arrange payment.

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