Healthcare Conti SRA Form

Healthcare Conti SRA Form

Purpose: This Continuity and Service Risk Assessment (Conti SRA) documents current clinical information, identified risks to safe continuation of care, and informed consent for continuation of services. Completion of this form assists the care team in planning ongoing treatment, mitigations for identified risks, and authorizations for information exchange as necessary for coordination of care.

Patient Information

Patient Name:    Date of Birth:

Insurance / Payer Information

Medical History and Current Status

Known risk factors (check all that apply):

Fall risk    Elopement / wandering risk    Self-harm or suicidal ideation    Infection control concerns

Plan of Care / Services to Continue

Risks, Benefits, and Consent

I understand that continuation of the recommended services has potential benefits including stabilization or improvement of condition, reduced risk of complications, and support for activities of daily living. I acknowledge there are also potential risks, which may include adverse reactions to treatments, increased fatigue, risk of falls or infection despite mitigation strategies, and the potential that expected benefits may not occur.

By checking the box below I provide my informed consent for the continuation of services as described above and for the care team to implement the mitigation strategies enumerated. I understand I may refuse or withdraw consent at any time by providing written notice, though withdrawal may affect the ability to provide ongoing services safely.

I consent to continuation of services and to the implementation of the stated mitigation strategies.

Authorization for Release / Exchange of Information

I authorize my healthcare providers and the care coordination team to exchange relevant medical and social information about me to facilitate ongoing care, including but not limited to diagnoses, medications, treatment plans, functional status, and risk assessments. This authorization includes release to other treating providers, payers, and service agencies as necessary for provision and coordination of care.

I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by privacy laws to the same extent. I may revoke this authorization at any time by providing written notice, except to the extent actions have already been taken in reliance on this authorization.

HIPAA / Privacy Acknowledgment

I acknowledge receipt of the facility's Notice of Privacy Practices and understand my rights under applicable privacy laws to access and request restrictions on my protected health information. I agree that disclosures permitted by this form are limited to the minimum necessary to accomplish the stated purpose of care coordination and continuity of services.

I acknowledge receipt of privacy notice and understand my rights.

Certification and Attestation

I certify that the information I have provided on this form is accurate to the best of my knowledge. I understand that falsification or omission of material information may jeopardize the safety or effectiveness of services and that the provider may decline or modify services based on assessed risk. I authorize release of information as described above and understand the rights to withdraw this authorization as described.

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