Healthcare ChildNet Form

HEALTHCARE CHILDNET FORM

Patient Information

Date of Birth:    Gender:

Parent / Legal Guardian (if patient is a minor)

Relationship to Patient:    Guardian Phone:

Insurance Information

Policy Number:    Group Number:

Emergency Contact

Relationship:    Phone:

Medical History

Authorization to Share Health Information (ChildNet)

I hereby authorize ChildNet and the medical providers identified below to disclose, exchange and receive the patient's protected health information (PHI) as necessary for coordination of care, service delivery, and continuity of treatment within the ChildNet network. This authorization includes the categories of information checked below.

Immunization records
Laboratory and diagnostic results
Medication list and prescriptions
Visit summaries and problem lists
Mental health and behavioral health records (if applicable)
Substance use treatment records (if applicable)
Entire medical record (all PHI)

Continuity of care / Treatment coordination
School or childcare health services
Billing and insurance claims
Program evaluation or research (de-identified when required)
Legal or administrative purposes
Other:

Authorization Terms, Rights and Notices

By signing below, I authorize the release and exchange of the specified PHI among ChildNet participants and designated recipients for the purposes set forth above. I understand that this authorization is voluntary and that I may refuse to sign; refusal will not affect my ability to obtain treatment, payment, enrollment, or eligibility for benefits except where permitted or required by law.

I understand that I may revoke this authorization in writing at any time by submitting a written revocation to the designated ChildNet program representative or the provider listed as a designated recipient. Revocation will not affect disclosures already made in reliance on this authorization prior to receipt of the revocation.

I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations. Some records, including certain mental health, substance use disorder, and HIV-related information, may require specific authorization; by checking the applicable boxes above I authorize disclosure of such sensitive records as indicated.

I certify that I am the patient or the patient's legal guardian or personal representative and that I have the authority to execute this authorization. I further certify that the information provided on this form is true and accurate to the best of my knowledge.

This authorization will expire on:    Or upon the occurrence of the following event:

Acknowledgment of HIPAA Notice and Rights

I acknowledge that I have been offered or provided a copy of the ChildNet Privacy Practices that explains how my health information may be used and disclosed and how I can obtain access to this information. I understand my rights to request restrictions, inspect and copy my health information, and to receive an accounting of disclosures as provided under applicable law.

If this authorization is signed by a personal representative, please indicate the authority to act on behalf of the patient (for example, parent, court-appointed guardian, healthcare power of attorney) in the relationship field below and provide documentation upon request.

Additional Authorizations and Notices

I understand that treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing this authorization except to the extent allowed by law. I further authorize ChildNet participants to use secure electronic exchange methods for transmitting PHI where necessary for the purposes named herein.

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