Healthcare FCCP Release Form

HEALTHCARE FCCP RELEASE FORM

Authorization for Release and Disclosure of Protected Health Information to the Family-Centered Care Program (FCCP). Patient Name: Date of Authorization:

PATIENT INFORMATION

Male Female Other / Prefer not to say

INSURANCE INFORMATION

MEDICAL HISTORY (BRIEF)

AUTHORIZATION TO RELEASE INFORMATION

I authorize the disclosure of my protected health information as specified below to the Family-Centered Care Program (FCCP) and its authorized staff. Recipient Organization Name: FCCP Coordinator / Contact:

Specific Information to be Released (check all that apply):

Medical records and treatment summaries
Medication lists and administration records
Laboratory and imaging results
Progress notes and care plans
Billing and insurance information related to FCCP services
Referral and discharge documentation

Sensitive Information (must be specifically authorized):

NOTE: Check each box only if you authorize release of these sensitive categories.
Mental health records and psychotherapy notes
Substance use disorder treatment records
HIV/AIDS related information

PURPOSE OF DISCLOSURE

Purpose(s) for release (check all that apply):
Care coordination and case management
Referral for services or follow-up care
Authorization, payment, or benefits eligibility verification
Quality review and program evaluation related to FCCP
Other:

DURATION / EXPIRATION

This authorization will expire on: or upon the occurrence of the following event:

RIGHT TO REVOKE / REDISCLOSURE

I understand that I may revoke this authorization at any time by providing a written notice of revocation to the FCCP privacy officer at the address listed above, except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect disclosures already made in reliance on this authorization. Information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by privacy rules.

FEES AND TREATMENT CONDITIONS

I understand that a reasonable fee may be charged for copying and preparing records in accordance with applicable law. I further understand that treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing this authorization unless the treatment is research-related or the provision of health care is solely for the purpose of creating protected health information for disclosure to a third party.

ACKNOWLEDGMENT OF HIPAA RIGHTS

By signing below I acknowledge that I have received and read the privacy notice provided by my health care provider and that I understand my rights under federal and applicable state privacy laws, including the right to inspect and obtain a copy of my health information.

CERTIFICATION

I certify that the information I have provided is true and that this authorization is given voluntarily. I understand that signing this form is my consent for release of the specified records to the Family-Centered Care Program and that a copy of this authorization is as valid as the original.

If signed by a personal representative, indicate relationship to patient and authority to act:

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