Healthcare Coordination Agreement

Healthcare Coordination Agreement

This Healthcare Coordination Agreement (the Agreement) documents the informed consent of the undersigned patient to allow coordinated health care activities, information exchange, and care management between the patient and the named care coordination entity. Patient Name: Care Coordination Entity:

Patient Information

Emergency Contact

Insurance Information

Medical History

Coordination Services — Scope and Purpose

The care coordination services include assessment, care planning, communication among treating providers, medication reconciliation, referral facilitation, scheduling assistance, and monitoring of care transitions. The Coordinator will act as a facilitator and does not assume primary medical responsibility for diagnosis or treatment. The Coordinator's responsibilities will include:

Consent to Exchange Health Information

I authorize the exchange and release of my protected health information (PHI) as reasonably necessary to perform the care coordination services described herein. This authorization permits electronic and paper exchange between the Coordinator and the following categories of persons or organizations (check all that apply):

Primary care provider

Specialists involved in my care

Hospitals and emergency facilities

Health plan or payer

Community service providers (e.g., home health, social services)

Permitted methods of communication (check all that apply):

Telephone calls to the numbers I provide

Email messaging to the address I provide

Text messaging / SMS to my mobile number

Secure patient portal messaging

I understand that I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance upon it. To revoke, I must provide written notice to the Care Coordination Entity named above. Revocation will not affect disclosures already made in reliance on this authorization.

Acknowledgement of limits: I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by recipients and may no longer be protected by privacy laws.

Privacy Practices & Patient Rights

I acknowledge that I have been given the opportunity to review the Privacy Practices of the Care Coordination Entity and that I have the right to request restrictions on certain uses and disclosures of my health information. I also understand my right to receive a copy of this signed Agreement.

I acknowledge receipt of the Privacy Practices and understand my rights described above.

Patient Responsibilities

The patient agrees to participate in care planning, to provide accurate information, to notify the Coordinator of changes in contact information or health status, and to follow up with providers as recommended. The patient understands that the Coordinator is not a substitute for emergency services and will contact emergency services when appropriate.

Fees, Billing and Costs

Coordination services may be billed to my insurer when permitted. I authorize the Care Coordination Entity to exchange necessary information with my insurer for billing and reimbursement purposes. I am responsible for co-payments or fees not covered by insurance and will be informed in advance of any expected charges.

I authorize billing and information exchange with my insurer as described above.

Limitation of Liability; Confidentiality and Data Security

The Coordinator will use reasonable administrative, technical, and physical safeguards to protect PHI. The Coordinator is not liable for unauthorized disclosures resulting from actions of third parties or from the patient's failure to provide accurate contact information. This Agreement does not create an independent duty of clinical care beyond coordination activity undertaken with the patient's consent.

Termination and Amendment

This Agreement remains in effect until the authorization expiration date specified above or until revoked in writing by the patient. The Care Coordination Entity may terminate services with notice to the patient consistent with applicable practice policies. Any amendment to this Agreement must be in writing and signed by the patient and an authorized representative of the Coordinator.

Governing Law and Dispute Resolution

This Agreement is governed by the applicable laws of the state in which the Care Coordination Entity operates. Any dispute arising under this Agreement shall first be addressed through the Coordinator's internal complaint process; if unresolved, the parties may pursue other remedies under applicable law.

Certifications and Acknowledgements

By signing below I certify that I am the patient or an authorized representative of the patient, that I have read and understand the terms of this Agreement, that I have had the opportunity to ask questions and receive answers, and that I voluntarily consent to the care coordination activities and information exchanges described herein.

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