Healthcare Health Connections Document

HEALTHCARE HEALTH CONNECTIONS DOCUMENT

Patient Information

Date of Birth:    Gender:

Insurance Information

Medical History & Current Conditions

Purpose and Scope of Health Connections Authorization

I authorize the release and exchange of my protected health information as set forth below for the purpose of care coordination, treatment, billing, referral management, continuity of care, and related health operations. This authorization specifically permits communication, record transfer, and direct contact between treating providers, care coordinators, and designated organizations identified below.

Types of Information To Be Shared (select all that apply)

Medical records (clinic notes, hospital summaries)
Laboratory and diagnostic test results
Immunization records
Medication and prescription history
Billing and insurance information related to the above
Mental health treatment notes (explicit authorization recommended)
Substance use disorder treatment records (explicit authorization required)
HIV/AIDS-related information (explicit authorization required)

Authorized Recipients / Organizations

Please list the providers, clinics, organizations, or individual care coordinators authorized to receive or exchange my information. Include name and relationship or role.

Method of Disclosure

Indicate permitted methods for sharing information (check all that apply):

Standard mail
Fax
Unencrypted email (I understand email may be less secure)
Telephone communication
Electronic health record portal or secure messaging

Duration, Expiration, and Revocation

This authorization is effective immediately upon my signature below and will expire on: . If I do not specify an expiration date, this authorization expires one year from the date signed.

I understand I may revoke this authorization in writing at any time by delivering a written revocation to the health information custodian identified in this document. Revocation will not affect disclosures already made in reliance on this authorization prior to receipt of the revocation.

Redisclosure and Limitations

I acknowledge that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy rules. I understand that if I authorize release of certain sensitive information, additional legal protections may not apply once disclosed.

Fee and Conditioning of Treatment

I understand there may be reasonable fees for copying and preparing records. I further understand that refusal to sign this authorization will not, with limited exceptions required by law, affect my ability to obtain treatment, payment, enrollment, or eligibility for benefits.

Acknowledgment of Privacy Practices

By signing below I acknowledge that I have received or been offered a copy of the Notice of Privacy Practices explaining how my health information may be used and disclosed. My signature also certifies that I have read and understand the terms of this authorization and that the information I have provided is accurate.

Patient Certification

I certify that I am the patient or the patient's legal representative and have the authority to execute this authorization. I understand the nature of this authorization and accept its terms.

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