Healthcare DSP Form

HEALTHCARE DSP FORM

Patient Information

Designated DSP (Direct Support Professional)

Designated DSP Name:

Agency or Employer (if applicable):

Scope of Authorization

By signing below the patient authorizes the Designated DSP to perform the services selected and to receive protected health information (PHI) necessary to perform those services. Select all that apply:

Schedule and Locations

Regular service days and times:

Insurance Information

Medical History & Current Status

Training, Competency & Limitations

The Designated DSP must demonstrate competency and receive documented training for any task that involves medication administration, wound care, or use of medical equipment. The patient authorizes only the following specific clinical tasks (check all that apply):

Authorization for Disclosure of Protected Health Information (PHI)

I authorize the release and disclosure of my protected health information to the Designated DSP for the purpose of coordinating care, training, treatment, and performing the services authorized above. This authorization includes access to assessment notes, medication lists, care plans, and appointment information to the extent necessary for the provision of authorized services.

I understand that information disclosed pursuant to this authorization may be re‑disclosed by the recipient and may no longer be protected by federal privacy regulations. The provider will limit disclosures to the minimum necessary to accomplish the stated purpose.

This authorization is voluntary. I may revoke this authorization at any time by providing written notice to the treating provider or facility; however, revocation will not affect disclosures already made in reliance on this authorization prior to receipt of the revocation.

Acknowledgments and Certifications

By signing below I certify that the information provided is true and accurate to the best of my knowledge. I acknowledge that:

• the Designated DSP will act only within the scope of this authorization and approved training;
• the provider and agency are not liable for actions of the Designated DSP that fall outside the scope of authorized services;
• I am responsible for notifying the provider and the DSP of any changes to care needs, medications, allergies, or emergency contact information;
• I have the right to revoke this authorization at any time by providing written notice to the treating provider or program.

I acknowledge that I have read and understand this authorization and the HIPAA privacy implications described above.

Miscellaneous

If the signatory is not the patient, indicate relationship and authority to sign (e.g., legal guardian, power of attorney):

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