Healthcare Health Consortium Form

Healthcare Health Consortium Form

This Healthcare Health Consortium Form authorizes the exchange and use of the patient's protected health information among participating consortium organizations for the purposes described below. Patient Name: Date of Birth:

Patient Information

Female    Male    Other/Prefer not to say

Emergency Contact

Insurance Information

Medical History (Relevant)

Authorization to Share Health Information

I authorize all participating members of the Healthcare Health Consortium to access, disclose, and exchange my protected health information as described below. This authorization includes information created before the date of signature and for the duration specified below.

All health information, including diagnoses, treatment records, laboratory and imaging results, and billing records
Mental health treatment records (where permitted by law)
Substance use disorder treatment records (where permitted by law)
HIV/AIDS testing and treatment records (where permitted by law)
Billing and payment information only

Treatment and care coordination
Payment and insurance facilitation
Quality improvement and patient safety activities
Research approved by consortium governance (de-identified where required)
Other:

Duration and Revocation

This authorization will expire on: . If no date is entered, this authorization expires one year from the date of signature. I understand I may revoke this authorization at any time by delivering a written revocation to the consortium's privacy officer. Revocation will not affect disclosures made prior to receipt of the revocation.

Redisclosure and Limitations

I understand that information disclosed under this authorization may be subject to redisclosure by the recipient and may no longer be protected by privacy law. Certain categories of information are protected by additional laws and will only be released in accordance with those laws unless I provide specific written authorization above. I understand that treatment, payment, enrollment, or eligibility for benefits is not conditioned on signing this authorization except as allowed by law.

Acknowledgments

I acknowledge receipt of the consortium's Notice of Privacy Practices and that I have the right to request a copy.
I have read, or have had read to me, and understand this authorization. I certify that the information I have provided on this form is true and correct to the best of my knowledge.

Additional Instructions / Limitations

Sign Now