Healthcare Community Form

HEALTHCARE COMMUNITY FORM

Patient Information

Date of Birth:    Gender: Male   Female   Other / Prefer not to say

Emergency Contact

Insurance Information

Medical History

Please indicate if you have been diagnosed with any of the following (check all that apply):

Diabetes   Hypertension   Heart disease   Asthma/COPD   Kidney disease   None of the above

Consent for Participation in Community Programs

I authorize participation in health education, screening, vaccination, counseling, and other community health programs provided by the organization. I understand that participation may involve collection of health information, basic clinical measures, and non-invasive procedures. I have had an opportunity to ask questions regarding the nature, purpose, and anticipated benefits and risks of recommended activities.

I acknowledge and consent to the following (check each box to indicate understanding):

I consent to participate in community health programs and recommended basic clinical services.
If this form is signed by a parent or legal guardian, I certify that I have legal authority to consent for the minor.
I understand that there may be minimal risks associated with screenings or interventions, which have been explained to me where applicable.
I understand I may withdraw consent at any time by notifying program staff in writing; withdrawal will not affect care already provided.

Authorization to Exchange Health Information

I authorize the release and exchange of my protected health information between the community program and identified partners for the purposes of care coordination, referral, eligibility determination for services, and public health reporting where required by law.

Authorization expiration date (if no date provided, authorization will expire one year from signature):

I understand that I may revoke this authorization at any time by providing written notice to program staff, except to the extent that the program has already acted in reliance on this authorization. I understand that information disclosed pursuant to this authorization may be redisclosed by the recipient and may no longer be protected by federal privacy regulations.

HIPAA Privacy Acknowledgment

I acknowledge that I have received or been offered a copy of the program's Notice of Privacy Practices describing how my health information may be used and disclosed and my rights under privacy laws. I understand that the notice describes the uses and disclosures of my health information and how I can exercise my rights.

I acknowledge receipt or offer of the Notice of Privacy Practices.

Photography / Video Release

For program outreach, education, and quality improvement purposes, staff may photograph or record participants. Images or recordings may be used in printed materials or internal reports. No personally identifying medical information will be published without additional written authorization.

I authorize non-identifiable photography/video for the purposes described above.
I decline photography/video release.

Acknowledgment and Certification

By signing below, I certify that the information I have provided on this form is true and accurate to the best of my knowledge. I authorize the community program and its partners to use my information as described in this form and understand my rights regarding privacy and revocation. I release program personnel from liability for routine activities conducted within the scope of the program and described in the consent sections, except in cases of willful misconduct or gross negligence.

I further certify that I have had the opportunity to ask questions and such questions have been answered to my satisfaction.

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