Healthcare Community Services Document

Healthcare Community Services Document

This Healthcare Community Services Document authorizes intake, coordination, and limited disclosure of protected health information as necessary to facilitate community-based services. Client Name: Date of Birth: Gender:

Patient Information

Insurance & Primary Provider

Medical History

Community Services Requested

Select services requested (check all that apply):

Authorization to Use and Disclose Health Information

I authorize the release and exchange of my protected health information (PHI) to support coordination of services and referrals between the healthcare provider or clinic named above and community partner organizations, service providers, payers, and care coordinators as identified below. This authorization specifically includes clinical summaries, medication lists, allergies, discharge summaries, and service plans necessary for care coordination.

The following sensitive information is included in this authorization only if I indicate below:

By initialing below, I acknowledge the specific inclusion of the sensitive categories I have selected: Initials:

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

Rights, Risks, and Acknowledgments

I understand that: (1) my participation in community services is voluntary; (2) I have the right to refuse to sign this authorization and that my refusal will not affect my right to receive treatment or to obtain benefits, except where treatment or program participation is conditioned on this authorization; (3) information disclosed pursuant to this authorization may be re-disclosed by the recipient and may no longer be protected by privacy laws; (4) records related to substance use disorder treatment are afforded special protections under federal law and additional consent may be required for redisclosure; and (5) I have the right to receive a copy of this authorization.

I acknowledge that I have been offered or provided the program's Notice of Privacy Practices describing how my health information may be used and disclosed.

Billing and Communications

I authorize the program to bill my insurance for services provided as part of community-based care coordination and agree that necessary billing information may be shared with payers as required to process claims.

I consent to receive appointment reminders and service communications via phone, text, or email at the contact information provided above. I understand standard message and data rates may apply.

Certification

By signing below I certify that the information I have provided is accurate to the best of my knowledge, that I have read and understand the statements on this form, and that I authorize the uses and disclosures described above.

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