Healthcare Health Due Diligence Form

HEALTH DUE DILIGENCE FORM

Patient Information

Patient Name:    Date of Birth:

Insurance Information

Medical History and Current Status

Due Diligence Assessment (Checklist)

Identity Verified: Yes     Photo ID Presented: Yes

Advance Directive on File: Yes     Power of Attorney / Guardian Documented: Yes

Medication Reconciliation Completed: Yes     Allergies Confirmed: Yes

Infection Control Status Reviewed: Yes     Immunization / COVID Vaccination Documented: Yes

Authorizations, Certifications and Notices

By signing below, I certify that the information provided on this Health Due Diligence Form is true and complete to the best of my knowledge. I authorize the release of the minimum necessary protected health information to facilitate internal due diligence reviews, care coordination, prior authorization processes, and quality-of-care assessments. This authorization includes review of medical records, medication lists, immunization records, allergy information, and advance directive documents.

I understand that this authorization is voluntary and that I may revoke it in writing at any time, except to the extent that action has already been taken in reliance upon it. If not earlier revoked, this authorization will expire on the date specified below or, if no date is specified, one year from the date of signature. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure and may no longer be protected by privacy laws.

I acknowledge receipt of the facility's privacy practices and understand my rights regarding access to my health information. I consent to the collection and verification of personal and health information necessary for the purposes stated above.

Medical records and clinical summaries     Medication lists     Immunization records

Allergy and adverse reaction history     Advance directives and POA documentation

Consent to Contact and Communications

I consent to being contacted by telephone, text message, and email for purposes related to care coordination and due diligence. I understand standard message and data rates may apply.

Phone     Text Message     Email

Attestations

I attest that I have disclosed all known allergies, current medications, and prior hospitalizations to the best of my knowledge. I understand that failure to disclose material information may affect clinical decision-making and care planning.

Sign Now