Healthcare Meraki Renewal Form

HEALTHCARE MERAKI RENEWAL FORM

This Healthcare Meraki Renewal Form serves to renew and update the patient’s prior authorization for participation in Meraki services and for the use and disclosure of protected health information as described below. Completion and signature confirm that the undersigned has read, understands, and agrees to the terms contained in this renewal.

Patient Information

Date of birth:    Gender: Female Male Other

Emergency Contact

Insurance Information

Medical History Update

Meraki Authorization Renewal

By signing below, I authorize the continued use and disclosure of my protected health information (PHI) to facilitate my participation in Meraki healthcare services. The PHI to be disclosed includes clinical assessments, treatment plans, medication lists, lab results, and scheduling information. The purpose of this disclosure is coordination of care, care management, billing, and quality improvement within the scope of the Meraki program.

Recipients authorized to receive my PHI include Meraki program staff, affiliated treating clinicians, care coordinators, and third-party vendors working on behalf of Meraki for treatment and administrative purposes. If I wish to specify other recipients, I list them here:

This authorization renews my existing authorization for the Meraki program. Choose the renewal term:

Renew authorization for 12 months from the date of signature.
Renew until:

Risks, Benefits, and Right to Revoke

I understand the benefits of permitting this information to be shared include improved coordination of care and enhanced access to Meraki services. Potential risks include the possibility of unauthorized re-disclosure by a recipient. I understand that signing is voluntary and that I may refuse to sign or may revoke this authorization at any time by providing written notice to Meraki program administration. Revocation will not affect disclosures made in reliance on this authorization prior to receipt of written revocation.

I understand that treatment, payment, enrollment, or eligibility for benefits will not be conditioned solely on signing this authorization, except if the disclosure is specifically required for enrollment in the Meraki program as described in program materials.

Communications & Telehealth Preferences

I consent to the following communications regarding my Meraki care (select all that apply):

Phone calls to primary number
SMS / text messages to primary number
Email communications to the address provided
Consent to participate in telehealth visits where clinically appropriate

Authorization to Obtain/Release Records

HIPAA Acknowledgment

I acknowledge that I have been provided with and offered an opportunity to review the applicable Notice of Privacy Practices and that I understand how my health information will be used and disclosed under this authorization. I understand that a copy of this signed authorization will be provided to me upon request and that a photocopy or electronic copy of this authorization is valid as the original.

I acknowledge receipt of the Notice of Privacy Practices and consent to disclosures as described herein.

Certification

I certify that the information provided on this renewal form is true and complete to the best of my knowledge. I understand that knowingly providing false information may subject me to penalties under applicable laws. I authorize Meraki program staff to update my record consistent with the information provided on this form.

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