Healthcare Medical Staffing UDS Form

HEALTHCARE MEDICAL STAFFING UDS FORM

Facility and Reporting Period

Reporting Month:    Reporting Year:    Contact Person:

Patient Information

Date of Birth:    Gender: Male Female Other

Phone:    Email:

Insurance Information

Policy Number:    Group Number:    Subscriber Name:

Medical History (Summary)

Assigned Medical Staffing (UDS Reporting)

Staff Entry 1

Roles (check applicable): Physician Nurse Practitioner Physician Assistant RN LPN Medical Assistant

License / Credential #:    Employment Status: FT PT Temp

Assigned FTE for Reporting Period:    Assignment Start Date:    Assignment End Date:

Staff Entry 2 (optional)

Roles (check applicable): Physician Nurse Practitioner Physician Assistant RN LPN Medical Assistant

License / Credential #:    Employment Status: FT PT Temp

Assigned FTE for Reporting Period:    Assignment Start Date:    Assignment End Date:

Staff Entry 3 (optional)

Roles (check applicable): Physician Nurse Practitioner Physician Assistant RN LPN Medical Assistant

License / Credential #:    Employment Status: FT PT Temp

Assigned FTE for Reporting Period:    Assignment Start Date:    Assignment End Date:

Service and Encounter Details

Encounter Date:    Service Code:    Hours Spent:

Encounter Type: Face-to-face Telehealth Home visit

UDS Metrics and Counts

Total Encounters in Reporting Period:    Unduplicated Patients Served:

Primary Provider FTE (sum for reporting period):    Behavioral Health FTE:

Consent, Certification, and Authorization

By signing below, I certify that the medical history and insurance information provided in this form are true and complete to the best of my knowledge. I authorize the facility to assign qualified licensed and credentialed staff listed above to provide medical services to me. I understand that staff assignments may change, that staff listed may act under supervision as required by law, and that I may request verification of credentials at any time.

I expressly authorize the disclosure of my protected health information, including limited demographic and service data, to be used for Uniform Data System (UDS) reporting and program monitoring. I understand that disclosures for UDS reporting will be limited to the minimum information necessary and de-identified whenever possible. This authorization does not authorize disclosure of psychotherapy notes except as required for reporting, and it does not authorize redisclosure beyond the purposes described.

I acknowledge that I have been informed of my rights under applicable privacy laws, including the right to withdraw this authorization at any time by delivering a written revocation to the facility's records custodian, except to the extent that action has already been taken in reliance on this authorization. Withdrawal will not affect disclosures already made in reliance on this authorization prior to receipt of revocation.

I understand that signing this form is voluntary and does not condition my receipt of treatment or enrollment in the program, except when the disclosure is necessary to determine eligibility or provide treatment as permitted by law.

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