Healthcare Community Health Document

Healthcare Community Health Document

Patient Information

Date of Birth:    Gender:    Preferred Pronouns:

Primary Phone:    Alternate Phone/Email:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy/ID Number:    Group Number:

Medical History

Community Health Services / Consent to Treatment

Description of Services:

I acknowledge that the community health services described above have been explained to me, including the anticipated benefits, common risks, and reasonable alternatives. I understand that no guarantees have been made regarding outcomes. I have had the opportunity to ask questions and receive answers.

I acknowledge I understand the risks and benefits associated with the services and consent to receive the services described.

I understand that my participation is voluntary and that I may withdraw consent at any time by providing written notice, without penalty to my access to other services.

HIPAA / Privacy Authorization

Authorization to Use and Disclose Protected Health Information (PHI): I authorize the disclosure of my PHI as necessary for the purposes indicated below. This authorization includes records relating to medical history, diagnosis, treatment, billing, and other health information related to services provided by the community health program.

Purpose(s) of Disclosure (check all that apply):

Care coordination and continuity of treatment   Billing and payment   Public health reporting and outreach   Program evaluation or approved research (de-identified where feasible)

Recipient(s) of PHI:

Expiration of Authorization: This authorization will expire on or upon occurrence of the following event:

Right to Revoke: I understand I may revoke this authorization at any time by submitting a written revocation to the community health program, except to the extent that action has already been taken in reliance on this authorization.

Redisclosure: I understand that once my PHI is disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations.

Acknowledgments and Certifications

I certify that the information I have provided on this form is true and correct to the best of my knowledge. I understand that withholding information relevant to my care may adversely affect the quality of services provided. I agree to inform the provider of any changes to the information on this form.

I acknowledge receipt of the Notice of Privacy Practices and have been given an opportunity to ask questions regarding how my PHI is used and disclosed.
I acknowledge receipt of the Notice of Privacy Practices.

Additional Authorizations

I authorize the program to leave voicemail messages and appointment reminders at the phone numbers provided.

I authorize exchange of relevant health information with caregivers, community partners, or agencies directly involved in my care.

Optional: Cultural / Communication Needs

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