Healthcare Management Services Registration

HEALTHCARE MANAGEMENT SERVICES REGISTRATION

Patient Information

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History

Do you have an advance directive, power of attorney, or similar legal document in effect? Yes No

Requested Management Services

Please indicate the healthcare management services you are registering for (select all that apply):

Care coordination and care planning
Medication management
Transitional care (hospital-to-home)
Chronic condition management
Telephonic or remote follow-up
Other (describe below)

Authorization, Consent, and Acknowledgments

By signing below I authorize Healthcare Management Services and its authorized representatives to provide the services identified above, to coordinate my care with my healthcare providers and insurers, and to access and disclose protected health information as necessary for care coordination, treatment, payment, and operations consistent with applicable law. This authorization includes release of medical records, medication lists, and immunization records to providers directly involved in my care.

I understand that participation in management services is voluntary. I may withdraw this authorization at any time by sending a written revocation to the organization identified below, except to the extent actions have already been taken in reliance on this authorization. Withdrawal will not affect information already released pursuant to this authorization while it was in effect.

I acknowledge that my healthcare management plan may involve communication by telephone, secure electronic message, or mail. I consent to routine contact at the phone numbers and electronic addresses I have provided. I understand that I have the right to request restrictions on disclosures and the right to request confidential communications.

I acknowledge that Healthcare Management Services will make reasonable efforts to safeguard my information but that no method of transmission or storage is completely secure. I release Healthcare Management Services from liability for incidental disclosure absent willful misconduct.

Authorization to disclose information for purposes other than treatment, payment, or healthcare operations requires a separate written authorization. This authorization will expire on the date indicated below or one year from the signature date if no expiration date is provided.

Billing, Fees, and Assignment

I understand that Healthcare Management Services may bill my insurer for care coordination and related services. I authorize assignment of benefits and direct payment to Healthcare Management Services for covered services. I agree to be responsible for applicable copayments, coinsurance, and amounts not reimbursed by my insurer according to the provider's billing policies.

If I am uninsured or if services are not covered, I will be notified of applicable fees and have the opportunity to accept or decline services before they begin.

Privacy and HIPAA Acknowledgment

I acknowledge receipt of the Notice of Privacy Practices of Healthcare Management Services and understand that the organization is required by law to maintain the privacy of my protected health information. By signing this form I indicate that I have been offered the Notice and that I understand my rights concerning my health information.

I consent to the use of electronic communications for the transmission of personal health information when necessary for care coordination and treatment. I understand I may revoke this consent in writing subject to the limitations described above.

Patient or Personal Representative must initial below to confirm understanding and consent:

Additional Authorizations

I authorize Healthcare Management Services to obtain medication lists, lab results, and other clinical records from hospitals, clinics, pharmacies, and laboratories for the purpose of care coordination. I further authorize the release of information to community resources and social services agencies as needed to support my care plan.

Certification and Warning

I certify that the information I have provided on this registration form is true and correct to the best of my knowledge. I understand that falsification of information may result in denial of services. I further understand that this form does not create a contractual obligation to provide services beyond the scope described and that services will be provided in accordance with established clinical policies and available resources.

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