Healthcare Management Form

HEALTHCARE MANAGEMENT FORM

Patient Information

Patient Name:

Date of Birth:    Gender: Female Male Other/Non-binary

Emergency Contact & Providers

Insurance Information

Medical History & Current Status

Care Management Preferences & Consents

I authorize the care management team to coordinate medical, social, and behavioral health services on my behalf, including discussion with other providers and payors as necessary for care coordination: Yes

I consent to receive appointment reminders and care-related communications via: Phone SMS/Text Email

Authorization to Disclose / Release Information (HIPAA Authorization)

I authorize the release and exchange of my protected health information among the care management team, listed providers, payors, and designated individuals for the purpose of care coordination, payment, and quality improvement. This authorization includes clinical records, medication lists, laboratory results, and care plans unless specifically limited below.

Limitations (specify records not to be released):

Release to Family / Support Person: Yes — Name(s):

Expiration: This authorization will remain in effect until revoked in writing or until the following date:

I understand that I may revoke this authorization at any time by submitting a written revocation to the care management program, except to the extent that action has already been taken in reliance on this authorization. I understand that treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing this authorization except where permitted by law.

Legal Acknowledgments & Certifications

By signing below I certify that the information provided on this form is accurate to the best of my knowledge. I authorize the care management team to obtain and exchange necessary health information for care coordination and payment purposes. I understand my rights regarding revocation of this authorization and the procedures to request restrictions on disclosures of my protected health information.

I acknowledge that I have received and been given opportunity to ask questions about the privacy practices and information sharing statements of the care management program, and that I retain the right to request limitations on disclosures as allowed by law.

Additional Consents

Telehealth/Remote Care Consent: I consent to receive care via telehealth when clinically appropriate and understand associated benefits and limitations.

Financial Assignment (if applicable): I authorize assignment of insurance benefits to the provider and acknowledge responsibility for charges not covered by insurance.

Sign Now