Healthcare Colleague Group Form

Healthcare Colleague Group Form

Group Identification

Group Name:

Individual Practitioner Group Practice Clinic Hospital Other:

Practice Location & Primary Contact

Group Billing & Insurance

Billing Agent / Administrator:

Group Members (List colleagues included in this group)

Provide current licensure and contact information for each colleague authorized to act on behalf of the group. Attach additional sheets if necessary.

If more colleagues are affiliated with this group, attach an additional sheet signed by the authorized representative certifying the accuracy of the attached list.

Scope of Authorization

By submitting this form, the group authorizes the healthcare organization to treat listed colleagues as authorized agents of the group for purposes of scheduling, referrals, access to aggregated practice reports, and limited shared access to patient records for continuity of care. This authorization does not itself confer clinical privileges or prescriptive authority beyond those held individually by each colleague.

HIPAA & Confidentiality Acknowledgment

The group and its listed colleagues acknowledge and agree that any access to protected health information (PHI) obtained pursuant to this authorization shall be used and disclosed only as permitted by applicable law and the receiving organization's privacy policies. The group warrants that it will instruct members regarding permitted uses, implement reasonable safeguards, and promptly notify the organization of any suspected unauthorized disclosures.

The group representative certifies that the group has obtained any necessary authorizations from patients for internal sharing of PHI and that the organization may rely on the list of colleagues furnished on this form for internal access and communication purposes.

Acknowledgment: I acknowledge and accept the HIPAA confidentiality obligations and attest that colleagues listed are permitted to access PHI consistent with the terms above.

Electronic Communications & Telehealth

The group consents to receive administrative communications (scheduling, billing, clinical notifications) electronically at the address provided. The group also indicates whether members will provide telehealth services under the group's umbrella.

Telehealth Participation: Yes No

Representations, Indemnity and Revocation

The group represents that all information provided on this form is true, complete and current. The group agrees to notify the organization in writing within ten (10) business days of any change to the list of colleagues, changes in licensure status, or changes to billing authority. The group agrees to indemnify and hold harmless the organization for claims arising from the group's failure to maintain necessary consents or from unauthorized acts of listed colleagues.

Revocation: The group may revoke this authorization in writing, which will be effective upon receipt and reasonable processing by the organization, except to the extent the organization has acted in reliance on the authorization prior to processing the revocation.

Certification

I certify under penalty of law that I am an authorized representative of the group identified herein, that the information supplied on this form is complete and accurate to the best of my knowledge, and that I am authorized to bind the group to the terms and conditions set forth in this form.

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