Healthcare HISP Application

HEALTHCARE HISP APPLICATION

This Healthcare HISP Application authorizes enrollment in secure health information exchange services provided by the Health Information Service Provider (HISP) designated by the practice or organization. Complete all sections in ink or type. The applicant affirms that the information provided below is true and authorizes the exchange of protected health information as described in the Authorization and Consent section of this form.

Patient / Applicant Information

Date of birth:    Gender:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy number:    Group number:

Medical History (brief)

Primary care physician:    Phone:

Requested HISP Services

Please indicate the HISP services you are requesting (check all that apply):

Secure Direct Messaging (clinical messages and referrals)
Query/Retrieve (patient record look-up)
Document Exchange (CCD/C-CDA transfers)
Laboratory Results Delivery
Referral and Care Coordination Transmission
Other:

Types of Information To Be Exchanged

I authorize the HISP to exchange the following categories of my health information (check all that apply):

General medical records (progress notes, problems, medications)
Mental health treatment records
Substance abuse treatment records
HIV/AIDS-related records
Genetic test results
Billing and insurance information

Authorization, Purpose, and Expiration

Authorization: I hereby authorize the HISP and any covered providers or their agents to access, use, and disclose my protected health information for the purposes checked above. This authorization includes the exchange of electronic clinical documents, messaging, and other electronic health information necessary to support care coordination, transitions of care, referrals, laboratory/result delivery, and administrative processing.

Purpose:

This authorization will expire on:    If no date is provided, this authorization will remain in effect until revoked in writing.

Risks, Benefits, and Alternatives

Benefits: Participation in secure health information exchange can improve coordination of care, reduce duplicate testing, and allow timely communication among treating clinicians.

Risks: Electronic transmission of health information involves potential risks, including but not limited to inadvertent disclosure, interception during transmission, or access by unauthorized persons despite efforts to secure data. The HISP will use industry-standard encryption and access controls; however, no method of transmission or storage is absolutely secure.

Alternatives: You may decline enrollment in HISP services. Declining will not affect your right to receive treatment; however, some types of electronic coordination of care may be limited.

Confidentiality, Security, and Liability

Confidentiality and Security: The HISP and participating providers will implement administrative, technical, and physical safeguards to protect electronic protected health information in accordance with applicable law. The HISP is authorized to use subcontractors as necessary, provided that appropriate confidentiality agreements are in place.

Liability: To the extent permitted by law, the HISP and participating entities shall not be liable for unauthorized disclosures resulting from your provision of inaccurate contact information, intentional release by parties you authorize, or failures outside the reasonable control of the HISP. You hereby release the HISP from claims arising from such disclosures, except where caused by willful misconduct or gross negligence.

Revocation

You may revoke this authorization at any time by providing a signed, written notice to the HISP's designated privacy officer or the practice's records department. Revocation will not affect disclosures made in reliance on this authorization prior to receipt of the revocation. Please provide revocation notice to:

HIPAA Acknowledgment

By signing below, I acknowledge that I have been provided with or offered a Notice of Privacy Practices that describes how my protected health information may be used and disclosed, and that I understand my rights with respect to that information.

Certification

I certify that the information I have provided on this application is true and correct to the best of my knowledge. I expressly authorize the HISP and participating providers to use and disclose my protected health information as described above. I understand that signing this form is voluntary and that I may revoke this authorization in writing at any time, subject to the conditions stated above.

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