Healthcare MCH Data System

HEALTHCARE MCH DATA SYSTEM

Program & Document Identification

Facility / Program Name:

Patient Demographic Information

Date of Birth:

Male    Female    Other    Prefer not to disclose

Program Enrollment & Eligibility

Enrollment Date:

Pregnant Parent    Postpartum    Infant/Child under 5    Family Services

Insurance and Primary Care

Medical & Maternal/Child Health History

Currently pregnant? Yes No    Breastfeeding? Yes No

If pregnant: Estimated Delivery Date:

Data Collection, Use, and Disclosure Authorization

Purpose: The Healthcare MCH Data System collects maternal and child health information to support clinical care, public health surveillance, program eligibility, care coordination, and quality improvement. Collected data may include demographic, clinical, laboratory, and service utilization information.

Authorization: By signing below, I authorize the disclosure and exchange of my and/or my child's protected health information as described in this form to authorized personnel and partner agencies for the purposes stated above. This authorization permits disclosure to clinical providers, public health entities, program partners, and case management teams.

Public Health Department    Primary Care Provider    Hospitals / Labor & Delivery    Program Partners / Case Managers

Rights, Duration, and Revocation

This authorization is voluntary. I understand that I may refuse to sign or may revoke this authorization at any time by submitting a written revocation to the program. Revocation will not affect disclosures made in reliance on this authorization prior to receipt of the revocation. Unless revoked sooner, this authorization will expire on the date specified below.

Expiration Date:

I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by law.

HIPAA Privacy Acknowledgment

I acknowledge that I have received or been offered the program's Notice of Privacy Practices describing how protected health information may be used and disclosed, and my rights with respect to such information. I understand that I may request restrictions on uses and disclosures and that requests will be considered in accordance with applicable law.

I acknowledge receipt of the Notice of Privacy Practices.

Data Correction & Contact

If I believe information in the MCH Data System about me or my child is incorrect, I may request an amendment and the program will process the request in accordance with applicable policies.

Phone    Email    Mail

Certification and Attestation

By signing below, I certify that the information provided on this form is true and correct to the best of my knowledge. I understand that knowingly providing false information may jeopardize eligibility for program services and may be subject to penalties under applicable law.

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