Healthcare Connectors Document

HEALTHCARE CONNECTORS DOCUMENT

This Healthcare Connectors Document authorizes the listed Healthcare Connector(s) to receive and act upon protected health information (PHI) and to assist with coordination of care, benefits, appointments, and related administrative tasks on behalf of the patient named below. This authorization is voluntary and is subject to the terms, scope, expiration, and revocation provisions set forth in this document.

Patient Information

Patient Name:

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History (brief)

Designated Healthcare Connector(s)

Connector 1

Connector 2

Connector 3 (optional)

Authorization and Scope of Access

I hereby authorize my health care providers and my health plan to disclose my protected health information to the above-named Healthcare Connector(s) for the purposes described in this document. The types of information authorized for disclosure are indicated below:

Medical records, including diagnoses and treatment summaries
Laboratory and imaging results
Prescription and medication history
Billing, claims, and insurance information
Appointment scheduling and referrals
Behavioral or mental health records (explicit consent acknowledged)
Other (specify):

Duration, Expiration, and Revocation

This authorization will remain in effect until the earlier of the following: the date indicated below, written revocation by the patient, or one year from the date of signature unless a different expiration is specified.

Revocation must be submitted in writing to the health care provider or health plan that holds the records. Revocation does not affect disclosures already made in reliance on this authorization prior to receipt of the revocation.

Redisclosure and Limits

I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations. I understand that health care treatment, payment, enrollment, or eligibility for benefits may not be conditioned on my signing this authorization, except when allowed by law and when necessary for the provision of certain services described by my provider.

Fees and Charges

I acknowledge that the recipient may be charged reasonable fees for copying and delivery of medical records as permitted by law. I agree that my Healthcare Connector may coordinate billing inquiries but is not authorized to sign financial agreements unless explicitly stated and authorized separately.

By signing below I certify that I understand the scope and effect of this authorization, that the information provided herein is accurate to the best of my knowledge, and that I may revoke this authorization as described above.

Acknowledgment of Privacy Practices

I acknowledge that I have been offered or provided the entity's Notice of Privacy Practices describing how my PHI may be used and disclosed. I understand that signing this form is my voluntary authorization for the disclosures described above.

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