Healthcare Lead Cage

HEALTHCARE LEAD CAGE INTAKE AND AUTHORIZATION

Lead Identification

Lead ID:    Intake Date:

Date of Birth:    Gender: Female Male Other/Prefer not to say

Primary Phone:    Secondary Phone:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy Number:    Group Number:

Subscriber DOB:

Medical Summary / History

Lead Engagement Details

Follow-up Attempts:    Last Contact Date:

New    Contacted    Scheduled    Declined    No Answer    Needs Additional Information

Consent to Contact & HIPAA Authorization

Purpose: I authorize the healthcare organization and assigned staff to contact me for scheduling, clinical triage, health reminders, insurance verification, and other care coordination related to the services requested.

Scope of Authorization: I authorize release and use of my protected health information (PHI) that is necessary for the purposes described above, including appointment details, scheduling notes, and limited clinical information for coordination and referral. This authorization does not permit disclosure of psychotherapy notes or other information specifically protected by law except as required for scheduling and coordination.

Communications: I understand communications may include telephone calls, voicemails, SMS/text messages, and unencrypted email. I acknowledge there are risks in transmitting PHI through unencrypted channels. I consent to receive communications at the numbers and email provided above.

Contact Permissions:
I authorize voice calls and voicemail messages.
I authorize SMS/text messages.
I authorize email communications.
I authorize postal mail.

Right to Revoke: I understand I may revoke this authorization at any time by providing written notice to the healthcare organization. Revocation will not affect disclosures already made in reliance on this authorization prior to receipt of the revocation.

Expiration: Unless earlier revoked, this authorization will expire on:

Acknowledgement of Privacy Practices: I acknowledge that I have been offered or provided a copy of the organization's Notice of Privacy Practices and understand my privacy rights with respect to protected health information.

Data Handling & Internal Use

Internal Handling (for administrative use): Add to CRM / lead system    Share with referral / intake team

Certification

By signing below I certify that the information provided in this lead intake form is true and accurate to the best of my knowledge. I authorize the use and disclosure of my protected health information consistent with the terms set forth in this form. I understand that consenting to contact does not obligate me to accept services and that I may revoke this authorization at any time in writing.

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