Healthcare Health Vigil Act

Healthcare Health Vigil Act

Preamble

This Healthcare Health Vigil Act Authorization ("Authorization") permits the collection, use, retention, and disclosure of the patient's protected health information for the limited purposes described below. Patient Name: Date of Birth:

Patient Information

Insurance Information

Medical History

Authorization and Scope of Data Collection

I authorize the collection, retention, and use of my protected health information as defined below for the purposes set forth in this Authorization. "Protected Health Information" includes medical records, clinical notes, laboratory results, imaging, vital signs, biometric indicators, wearable device data, and limited location data collected for health monitoring.

I CONSENT to collection and use of the following categories of data (check all that apply):

Electronic Health Record clinical data (EHR)

Laboratory results and diagnostic reports

Imaging and radiology data

Wearable device and biometric sensor data (heart rate, activity, SpO2, etc.)

Limited location/movement data collected for health monitoring

Other health-related data as specifically described:

Permitted Uses and Disclosures

I authorize disclosure and use of my protected health information for the following purposes (check all that apply). These disclosures may be to internal care teams, affiliated entities, public health authorities, and contractual agents engaged for authorized activities.

Clinical care and coordination among treating providers

Public health surveillance, reporting, and outbreak response

Research and population health studies (de-identified where applicable)

Quality improvement, program evaluation, and health operations

Billing or insurance claim processing where necessary

Recipients of Disclosed Information

I authorize disclosure to the following categories of recipients (check all that apply):

Treating physicians, nurses, and clinical staff

Affiliated health system entities and care partners

Public health departments and authorized public health entities

Research organizations and institutional review boards when applicable

Contracted service providers performing authorized functions

Limits, Redisclosure, and Protections

I understand that once my protected health information is disclosed pursuant to this Authorization, the recipient may re-disclose it in accordance with applicable law. Certain disclosures for research and public health purposes may be de-identified consistent with accepted standards. Reasonable safeguards will be applied to protect the information, but absolute confidentiality cannot be guaranteed.

Right to Revoke and Expiration

I understand that I may revoke this Authorization at any time by delivering a written revocation to the health records or privacy office of the treating provider identified on my care record. Revocation will be effective upon receipt, except to the extent that disclosures have already been made in reliance on this Authorization. Revocation does not affect disclosures made before the revocation.

HIPAA / Privacy Acknowledgment

By signing below I acknowledge that I have received or been offered the provider's Notice of Privacy Practices describing the use and disclosure of my protected health information and my rights with respect to such information.

I acknowledge receipt or offer of the Notice of Privacy Practices

Voluntary Nature and Effects of Refusal

I understand that signing this Authorization is voluntary. Refusal to sign will not affect my ability to receive treatment, payment, enrollment or eligibility for benefits, except to the extent that collection of the specified data is necessary for a requested monitoring program or public health activity of which I have been informed.

Certifications

By signing below I certify that I am the patient or I am authorized to act on behalf of the patient and that the information I have provided is true and complete to the best of my knowledge. I authorize the uses and disclosures described in this Authorization and understand the rights and limitations set forth herein.

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