Healthcare CommCare Extension

HEALTHCARE COMMCARE EXTENSION

This Healthcare CommCare Extension documents the patient request and clinical authorization to continue CommCare home- or community-based services, remote monitoring, or care coordination under the existing plan of care. Patient Name: Date of Birth: Medical Record / ID:

Patient Information

Male Female Other Decline to State

Emergency Contact

Insurance Information

Medical History (brief)

Requested Extension — CommCare Services

Services to be continued (check applicable): Case Management Remote Monitoring In-Home Visits Telehealth Other

Risks, Benefits, Alternatives & Costs

The patient understands that continuation of CommCare services is intended to support health stabilization, care coordination, and avoidance of higher-level care. Benefits may include improved symptom control and enhanced access to the care team. Risks include potential limitations of remote assessment and the possibility that identified needs may require escalation to urgent or facility-based care. Alternatives include modifying frequency of services, referral to specialty care, or discontinuation of CommCare services.

Patient acknowledges financial responsibility for applicable copayments and deductibles under their insurance, and that prior authorization by insurer may be required. Patient will be notified if services are not covered and will be responsible for non-covered charges if they elect to proceed.

I acknowledge that I have been informed of the risks, benefits, and alternatives described above.

Authorization & HIPAA Acknowledgment

By signing below, I authorize the provider and its staff to continue to provide the CommCare services indicated above and to disclose protected health information to members of my care team and to third-party payors as necessary to facilitate care and billing. I understand that this authorization includes verbal and written communication, secure electronic messages, and use of telehealth or remote monitoring devices when applicable.

I have received and acknowledge the agency's privacy practices and understand my rights under applicable privacy laws, including the right to revoke this authorization in writing except to the extent that action has already been taken in reliance on it.

I understand that this authorization will remain in effect until the expiration date entered below or until I revoke it in writing. Any revocation must be provided to the provider's records department and will not be effective to the extent that providers have already acted in reliance on the authorization.

I acknowledge and authorize the disclosures described above.

Additional Instructions / Clinical Notes

Patient Certification

I certify that the information provided on this CommCare Extension form is accurate to the best of my knowledge. I understand that falsification of information may affect eligibility for services. I understand that I may revoke this authorization at any time in writing, except where actions have already been taken pursuant to this authorization.

Sign Now