Healthcare Migration Agreement

Healthcare Migration Agreement

Patient Name:    Date of Birth:    Medical Record No.:

Patient Information

Insurance Information

Medical History (Summary)

Recipient / Destination for Migration

Scope of Records to Be Migrated

Select records to be transferred (check all that apply):

Complete medical records

Laboratory and pathology results

Radiology / imaging studies and reports

Medication history and prescriptions

Immunization records

Billing and insurance claims records

Mental health and psychotherapy notes (explicit authorization required)

Substance use disorder treatment records (explicit authorization required)

HIV/AIDS-related records (explicit authorization required)

If any of the sensitive categories above are selected, I specifically acknowledge and authorize the release of those records by initialing here:

Date range for records to be migrated: From to

Method and Security of Transfer

Secure electronic transfer (direct EHR-to-EHR interface)

Encrypted portable media (USB, CD)

Paper records (secure courier)

Other:

Recipient shall employ industry-standard technical and administrative safeguards to protect the confidentiality and integrity of electronic health information during transmission. I acknowledge that the recipient will use reasonable encryption and access controls to the extent practicable and required by law.

Fees, Revocation, Expiration

I understand that reasonable copying or transmission fees may apply. Patient agrees to pay any third-party vendor charges required for the migration: I agree to be responsible for reasonable fees

Authorization expiration (unless earlier revoked):

Representations, Liability, and Governing Law

Recipient represents that it will limit access to migrated records to authorized personnel and will not use or disclose the records except as permitted by this agreement and applicable law. Except where prohibited by law, neither the releasing organization nor its employees shall be liable for indirect, incidental, or consequential damages arising from loss of access to data after a verified successful transfer.

Governing law for interpretation and enforcement of this authorization:

HIPAA Privacy Acknowledgment

By signing below I acknowledge that I have received and reviewed the privacy practices notice of the releasing organization and understand my rights regarding protected health information. I authorize release and migration of the records described above to the recipient for the stated purpose.

I acknowledge receipt of the privacy practices notice and authorize this migration.

Certification by Patient

I certify that the information provided in this Healthcare Migration Agreement is true and correct to the best of my knowledge. I understand that this authorization permits release of confidential health information to the recipient identified above for the purposes described and that I may be charged a reasonable fee for copies or transfers. I understand that I may revoke this authorization at any time in writing, except to the extent that action has already been taken in reliance on it.

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