Healthcare MDT Packet Template

HEALTHCARE MDT PACKET TEMPLATE

Patient Information

Date of Birth:    Gender:    MRN/ID:

Primary Phone:    Alternate Phone:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy Number:    Group #:    Subscriber Name:

Referral and Referral Reason

Date of Referral:    Primary Diagnosis:

MDT Meeting Details

Meeting Date:    Meeting Time:    Location:

Physician:

Nurse:

Social Worker:

Physical Therapy:    Occupational Therapy:

Speech-Language Pathology:

Psychology/Psychiatry:

Case Manager:    Family/Support:

Clinical Assessments & Status

Medical History, Medications & Allergies

Social / Environmental Assessment

Patient Goals & Preferences

MDT Recommendations & Plan

Risk, Advance Directives & Code Status

Fall Risk Identified:    If yes, describe precautions and interventions below.

Authorization to Disclose Protected Health Information (PHI)

By signing below I authorize the release and exchange of my protected health information among members of the multidisciplinary team identified in this packet for the purpose of care coordination, treatment planning, and service provision. This authorization includes disclosures of medical records, treatment summaries, medication lists, functional assessments, behavioral health information, and social service notes as necessary for the MDT process.

I understand that I may revoke this authorization at any time by providing a written notice of revocation to the health record custodian; however, revocation will not apply to information already disclosed in reliance on this authorization. Unless earlier revoked, this authorization expires on the date specified below or, if no date is provided, one year from the date of signature.

Sensitive information which may be disclosed includes but is not limited to mental health records, substance use treatment records, HIV-related information, and genetic test results insofar as such information is necessary for the MDT to perform clinical functions. I understand that authorizing disclosure of such information is voluntary.

I acknowledge that information shared under this authorization will be handled in accordance with applicable privacy laws and institutional policies. Recipients of disclosed information may re-disclose it only in accordance with law.

HIPAA Privacy Acknowledgment

I acknowledge that I have received or been offered the facility's Notice of Privacy Practices describing how my protected health information may be used and disclosed and my rights with respect to that information.

I acknowledge receipt of the Notice of Privacy Practices

Patient Certification

I certify that the information provided in this packet is accurate to the best of my knowledge. By signing below, I authorize the persons and organizations listed in this packet to share and discuss my protected health information for the purposes described herein and consent to participation in MDT activities.

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