Healthcare HealthLink Agreement

HEALTHCARE HEALTHLINK AGREEMENT

Patient Identification

Patient Name:

Date of Birth: Gender:

Insurance Information

Medical History (Brief)

Authorization and Purpose

I authorize the exchange of my protected health information through the HealthLink network and its participating clinical entities for the purposes indicated below. This authorization permits electronic sharing and retrieval of records between authorized providers, health systems, and their agents as necessary to accomplish the listed purposes.

Purpose(s) (check all that apply):

Treatment, care coordination, clinical decision-making

Payment, claims adjudication and related billing activities

Healthcare operations, quality measurement, and population health

Approved research or public health activities where legally permitted

Scope of Information and Sensitive Data

The types of health information that may be exchanged include, but are not limited to: clinical notes, problem lists, medication lists, laboratory and imaging results, allergies, immunizations, and discharge summaries. This authorization does not automatically include certain categories of highly sensitive information unless expressly indicated below.

Include sensitive categories (check to permit sharing):

Substance use disorder treatment records subject to special protections

Mental health psychotherapy notes and behavioral health records

HIV/AIDS and other communicable disease treatment information

Genetic testing and related genetic information

Authorized Recipients and Sharing Settings

I authorize HealthLink to disclose my health information to the following designated entities or to all participating providers as indicated.

Share with all participating HealthLink providers and affiliated entities

Duration, Revocation, and Expiration

This authorization is effective on the date signed below and will remain in effect until the earlier of the expiration date provided by me or revocation in writing. To revoke this authorization, I must deliver a written revocation signed by me or my authorized representative to the HealthLink privacy office or to the provider(s) that hold my records. Revocation does not affect disclosures made in reliance on this authorization prior to receipt of revocation.

Privacy, Redisclosure, and Liability

I understand that information disclosed pursuant to this authorization may be re-disclosed by the recipient and no longer protected by federal privacy regulations. HealthLink and its participants will implement reasonable administrative, technical, and physical safeguards to protect my information, but cannot guarantee absolute security. HealthLink and participating providers are not liable for unauthorized re-disclosure by third parties beyond their control.

I acknowledge that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on my signing this authorization except where allowed by law for research-related activities.

Patient Rights and Acknowledgments

I have the right to receive a copy of this signed authorization. I understand that I may inspect or obtain a copy of the health information that is subject to this authorization, subject to applicable law. I certify that I have read and understand the terms of this Healthcare HealthLink Agreement and that I am authorized to make decisions regarding the use and disclosure of my protected health information.

I acknowledge that I have been given the opportunity to ask questions about this authorization and that those questions have been answered to my satisfaction.

Acknowledgment

I request a copy of this signed authorization

I acknowledge that services will not be conditioned on signing this authorization unless permitted by law

Sign Now