Healthcare Health Update Project

HEALTHCARE HEALTH UPDATE PROJECT

Purpose: The Healthcare Health Update Project collects current health, insurance and contact information to coordinate ongoing care, update the medical record, and permit limited sharing of health information among authorized project clinicians and administrative staff. Completion of this form authorizes updates to your record and limited disclosures as described below.

Patient Information

Date of Birth:

Female Male Other Prefer not to say

Emergency Contact

Insurance Information

Subscriber Date of Birth:

Medical History & Current Status

No known allergies Medication Food Environmental Other

Diabetes Hypertension Heart disease Asthma / COPD Kidney disease Other

I am currently receiving treatment or have recent concerns

Current or recent use

Functional Status & Preventive Care

Do you require assistance with mobility or activities of daily living? Yes No

Influenza Tetanus Hepatitis B COVID-19 Other

Consent, Authorization & Privacy

Authorization for Use and Disclosure: I authorize the release and exchange of my protected health information, as necessary to update my medical record and to coordinate my care within the Healthcare Health Update Project. Information that may be disclosed includes medical history, medication lists, allergies, recent test results, and treatment plans. This authorization permits disclosure to project clinicians, care coordinators, and administrative staff who have a legitimate need to access my records for treatment, care coordination, quality improvement and project administration.

Expiration: This authorization will expire on the date entered below or upon written revocation, whichever occurs first. I understand I may revoke this authorization at any time by submitting a written notice to the project administrator. Revocation will not apply to information already disclosed in reliance on this authorization prior to receipt of the revocation.

Authorization Expiration Date:

Acknowledgment of Privacy Practices: I acknowledge that I have been provided with or offered a copy of the project’s privacy practices describing how my health information may be used and disclosed and my rights with respect to that information. I understand that my care will not be conditioned on signing this authorization except where permitted by law.

Certification of Accuracy: I certify under penalty of law that the information I have provided on this Health Update form is true, complete, and accurate to the best of my knowledge. I understand that knowingly providing false information may have legal consequences and may adversely affect my care.

Consent to Treatment: By signing below I consent to routine treatment by qualified personnel associated with the Healthcare Health Update Project. I understand that I may ask questions and have the right to refuse any treatment. This consent is valid only for treatments reasonably related to the care coordination and clinical services provided through the project.

Patient Acknowledgement: I acknowledge and agree to the terms above.

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