Healthcare Medical Network Form

HEALTHCARE MEDICAL NETWORK FORM

Patient Information

Patient Name:

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History

Chronic Conditions (check all that apply):

Diabetes    Hypertension    Heart disease    Asthma    Cancer

Primary Care and Network Participation

Primary Care Provider (PCP):

I consent to participate in the medical network's coordinated care program. Participation authorizes network providers and their affiliated personnel to share and access my medical records, treatment plans, and care coordination notes as necessary to provide integrated care, subject to the Privacy Practices acknowledged below.

I authorize the network to contact me for care coordination and appointment reminders at the contact information provided. I understand that standard telehealth and electronic communications risks apply.

Communication preferences:

Phone calls    Text messages    Email

Assignment of Benefits and Release

Assignment of Benefits: I assign to participating network providers all rights and benefits payable under my health insurance or other third-party payor for services rendered by network providers. I understand that I remain financially responsible for any non-covered services, co-payments, deductibles, and charges not paid by my insurer.

Release of Information: I authorize release of my medical information, including diagnoses, treatment records, and billing information, to my insurer, case managers, and other network providers as reasonably necessary for payment, treatment, and health care operations.

I acknowledge and agree to the Assignment of Benefits and Release of Information terms above.

HIPAA Privacy Authorization and Acknowledgment

By signing below I acknowledge receipt of the network's Notice of Privacy Practices and understand how my protected health information may be used and disclosed for treatment, payment, and health care operations. I authorize the disclosure of protected health information as described in this form and in the Notice of Privacy Practices to network providers and their agents for care coordination and related activities.

Right to Revoke: I understand that I may revoke this authorization at any time by submitting a written revocation to the network except to the extent that action has already been taken in reliance on this authorization. I understand that revocation will not affect disclosures made prior to receipt of the revocation.

Authorization expires on:

I authorize the uses and disclosures described above and acknowledge receipt of the Notice of Privacy Practices.

Consent for Treatment

I consent to diagnostic and therapeutic services, including examinations, laboratory tests, immunizations, and routine procedures performed by authorized network providers. I understand risks and benefits will be explained for any procedure requiring specific informed consent and that I may withdraw consent at any time prior to a procedure.

I consent to treatment by network providers as described above.

Certification

I certify under penalty of perjury that the information provided on this form is true and complete to the best of my knowledge. I understand that falsification of information may result in denial of benefits, termination of participation, or other administrative actions allowed by law or network policy.

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