Healthcare Connect Agreement

HEALTHCARE CONNECT AGREEMENT

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance Information

Medical History (Relevant)

Authorization: Purpose, Scope, and Recipients

I authorize the exchange of my protected health information among the following categories of entities for the purposes checked below:

Providers involved in my direct care    Health plans / insurers    Care coordinators / case management

Pharmacies    Laboratories / Imaging centers    Other:

Types of Information to Be Shared

The following categories may be included in the exchange unless expressly excluded below:

Medical history, problem lists, encounter summaries    Medication lists and prescriptions

Allergies and adverse reactions    Laboratory and imaging results

Behavioral health notes    Sensitive information (mental health, substance use, HIV, genetic) — include only if initials:

Authorization Period and Revocation

This authorization becomes effective on: and will expire on: unless earlier revoked in writing.

I understand that I may revoke this authorization at any time by providing a written notice to the health information custodian identified below. Revocation will not affect disclosures already made in reliance on this authorization prior to receipt of the revocation.

Authorization and Legal Acknowledgments

By signing below I authorize the release and exchange of my protected health information as set forth in this Healthcare Connect Agreement. I acknowledge that I have read and understand the purpose of this disclosure, that my consent is voluntary, and that my treatment, payment, enrollment or eligibility for benefits will not be conditioned on signing this authorization except where permitted by law.

I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy law. Entities receiving information pursuant to this authorization are requested to maintain confidentiality and to limit use to the purposes identified herein.

Security, Technical Access, and Liability

Entities participating in this exchange will use administrative, technical, and physical safeguards designed to protect the confidentiality and integrity of my health information. However, no system is completely secure and I understand there may be risks associated with electronic exchange of information.

By authorizing exchange I do not waive any legal rights. Neither the health information custodian nor its agents will be liable for inadvertent disclosure resulting from the authorized exchange unless such disclosure is caused by willful misconduct or gross negligence.

Acknowledgment of Privacy Notice

I acknowledge that I have been provided with the opportunity to review the privacy practices of the health information custodian and that I understand my rights regarding use and disclosure of my protected health information.

I further acknowledge that I may request a copy of this signed authorization.

Optional: Additional Instructions or Restrictions

Contact for Questions

Patient Certification and Consent

I certify that the information I have provided is true and complete to the best of my knowledge. I authorize the use and disclosure of my protected health information as described above and accept the terms and conditions set forth in this Healthcare Connect Agreement.

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