Healthcare Contact Letter

HEALTHCARE CONTACT LETTER

Facility / Provider Name:

Patient Information

Patient Name:    Date of Birth:    Medical Record No.:

Emergency Contact

Insurance Information

Medical Summary

Authorization to Contact / Disclose

By signing this Healthcare Contact Letter, I authorize the above-named facility or provider to contact and disclose the patient’s protected health information to the individuals listed below for the purposes expressly indicated. Disclosure is limited to the scope described and will be used solely for the agreed purposes unless otherwise required by law.

I authorize disclosure for the following purposes (check all that apply):
Scheduling and appointment reminders    Care coordination and treatment planning    Billing and insurance matters    Emergency notification    Other (see description below)

Authorized Contacts (Primary to be contacted first)

Relationship:    Phone:    Email:

Access Level: Limited information only (scheduling, basic status)    Full access to discuss medical and billing information

Relationship:    Phone:    Email:

Access Level: Limited information only    Full access to discuss medical and billing information

Relationship:    Phone:    Email:

Access Level: Limited information only    Full access to discuss medical and billing information

Limits, Messaging, Expiration and Revocation

Special limitations on disclosure (if any): the undersigned limits disclosure as follows:

Permission to leave voicemail or text messages regarding appointments or health information:   Yes    No

This authorization will expire on: . If no date is provided, this authorization expires one year from the date signed below unless revoked earlier in writing.

Revocation: I understand that I may revoke this authorization at any time by delivering a written revocation to the facility or provider’s medical records department. Revocation will not affect disclosures made in reliance on this authorization prior to receipt of the written revocation.

HIPAA Acknowledgment and Conditions

I acknowledge that I have been offered or received the facility’s Notice of Privacy Practices describing how my health information may be used and disclosed and my rights under federal privacy law. I understand that information disclosed pursuant to this authorization may no longer be protected by federal privacy regulations and may be redisclosed by the recipient.

Certification: I certify that I am the patient or I am legally authorized to act on behalf of the patient. I have read and understand this authorization and the consequences of signing. By signing below I authorize the disclosures described above.

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