Healthcare Health Promoters Document

Healthcare Health Promoters Document

Purpose and Scope

This document records the patient's informed consent and acknowledgment for community health promoter outreach, care coordination, and limited information sharing to support prevention, treatment adherence, health education, and social needs referral. Health promoters act to facilitate communication between the patient and health services and do not replace clinical care providers.

Patient Information

Health Promoter / Outreach Information

Contact Preferences & Authorizations

Preferred method(s) of contact (check all that apply):

Phone Text / SMS Email Postal Mail

I consent to being contacted at the phone numbers and email provided above for care coordination, appointment reminders, health education, and referral follow-up. Text messages may be unencrypted and may be received by others with access to my device. I understand message frequency may vary and message/data rates may apply.

Consent to contact: Yes    No

Insurance Information

Medical History (for outreach relevance)

Authorization to Use and Disclose Protected Health Information (PHI)

I authorize my healthcare providers and records custodians to disclose the limited PHI described below to the named health promoter(s) and their supervising organization for the purpose of outreach, care coordination, referral, follow-up, and health education.

Medical diagnoses and treatment plans Medication lists Appointment dates and reminders Referrals and social needs resources

Limitations on disclosure (specify if you wish to limit any categories above):

I understand that information disclosed pursuant to this authorization may include information created before the date of this authorization and may include sensitive information such as behavioral health, HIV-related information, or substance use treatment records unless I have specifically indicated a limitation above.

Voluntary Nature, Revocation, and Expiration

I understand that signing this authorization is voluntary. I may revoke this authorization at any time by providing a written notice to the health promoter organization and to my healthcare provider, except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect uses or disclosures made prior to receipt of the revocation.

If no expiration date is specified, this authorization will expire one year from the date of signature unless state law requires a different period.

Privacy, Confidentiality and Limits

Health promoters are trained in confidentiality and will take reasonable steps to protect your information. However, confidentiality is not absolute. Promoters and providers must disclose information if required by law, such as reports of suspected abuse or neglect, imminent threats of harm to self or others, or pursuant to a court order. Promoters do not provide clinical diagnosis or emergency medical services.

Acknowledgment and Certifications

By signing below I certify that I have read and understand this authorization. I have had the opportunity to ask questions about the role of the health promoter, the scope of information to be shared, the potential benefits and risks of outreach activities, and how to revoke this authorization. I understand that refusal to sign will not affect my ability to obtain treatment, payment, enrollment, or eligibility for benefits.

I acknowledge receipt of a privacy notice that describes the uses and disclosures of my health information. I understand the limits to confidentiality described above.

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