Healthcare Disabilities Services Form

HEALTHCARE DISABILITIES SERVICES FORM

Purpose: This form collects information necessary to evaluate eligibility for disability-related healthcare services, develop a service plan, and obtain informed consent and limited authorization to share records for coordination of care. Information provided is confidential and will be used only as permitted by law, the terms of this authorization, and organizational policy.

Patient Information

Date of Birth:    Gender: Male Female Non-binary Other

Emergency Contact

Disability and Functional Profile

Disability onset or diagnosis date:

Physical Sensory Cognitive Developmental Psychiatric Intellectual Multiple Other

Wheelchair Cane Walker Prosthesis None Other

ASL / Interpreter Large print Simple language Assistive communication device Other

Services Requested

Case management Therapy (PT/OT/Speech) Personal assistance Assistive technology Transportation Vocational services Housing support Other

Medical and Insurance Information

Consent and Authorization

Consent to Services: I authorize the provider to deliver disability-related assessments, care coordination, and the services requested above. I understand services are voluntary, that the provider will explain proposed interventions, and that I may decline or withdraw consent at any time by providing written notice. Withdrawal of consent may affect the ability to continue services.

Authorization to Use and Disclose Protected Health Information: I authorize the provider to obtain and disclose limited health information necessary to assess needs and coordinate services, including but not limited to medical records, medication lists, and treatment summaries, to other providers, payers, and contracted service agencies for the purpose of treatment, care coordination, and billing. This authorization does not authorize disclosure beyond these purposes unless I sign a separate release.

Revocation: I may revoke this authorization at any time by submitting a written revocation to the provider's designated privacy official. Revocation will not affect disclosures made prior to the receipt of the revocation. This authorization will expire on the date specified above or, if no date is specified, one year from the date of signature.

I consent to emergency medical treatment if, in the opinion of the provider, I require immediate care. I understand efforts will be made to contact my emergency contact prior to actions taken when practicable.

I authorize release of records and information to other agencies and providers as needed for coordination of services and benefits.

Privacy Notice Acknowledgment

I acknowledge that I have been provided with or offered a copy of the provider's privacy practices describing how my protected health information may be used and disclosed, and my rights with respect to that information.

I acknowledge receipt or offer of the privacy notice.

Client Rights and Responsibilities

Rights: You have the right to be treated with dignity and respect; to receive services in a safe environment; to be informed about the assessment findings and proposed services; to refuse services; and to file complaints about care without retaliation.

Responsibilities: You are responsible for providing accurate information, attending scheduled appointments when possible, notifying the provider of changes in health or insurance status, and participating in service planning to the extent possible.

Signature

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