Healthcare Migration Form

HEALTHCARE MIGRATION FORM

Patient Information

Patient Name:

Date of Birth:   Gender:

Insurance and Subscriber Information

Current Provider (Source)

Receiving Provider (Destination)

Records to Be Migrated

Progress notes

Imaging reports (radiology, MRI, CT)

Laboratory results

Medication history and prescriptions

Billing records and claims

Immunization records

Psychotherapy notes (requires explicit authorization)

Complete medical record (all available sections)

Method and Format of Transfer

Preferred Format: Electronic (structured) CCDA/CCD PDF

Transmission Method: Secure FTP Encrypted email Direct / Health information network Paper (mailed or hand-delivered) Fax

Medical History Summary

Authorization to Release and Migrate Records

I, the undersigned patient or legal representative, hereby authorize the Current Provider named above to disclose and transfer my protected health information to the Receiving Provider for the purposes of continuity of care, treatment planning, coordination of services, and administration. This authorization includes the categories of records selected above and any other information reasonably necessary to effectuate the migration.

I understand and acknowledge that electronic transfer may result in temporary changes to format or the combining of records from disparate systems. Reasonable safeguards will be used to protect the confidentiality and integrity of my health information during transfer. I acknowledge the potential, although unlikely, risks associated with electronic transmission including unintended access during transmission.

I understand that psychotherapy notes, if included, are specially protected and that I have indicated explicit consent to include them above. I understand that treatment, payment, enrollment, or eligibility for benefits may not be conditioned upon signing this authorization except where allowed by law.

I may revoke this authorization at any time by providing a written notice to the Current Provider's Privacy Office, except to the extent that the action has already been taken in reliance on this authorization. This revocation will not affect disclosures made prior to receipt of my revocation.

Fees: I acknowledge that a reasonable fee may be charged for copying or transferring records as permitted by law. Payment method and arrangements (if applicable):

Acknowledgments and Certifications

By signing below I certify that I am the patient or am authorized to act on behalf of the patient. I certify that the information provided in this form is true and accurate to the best of my knowledge. I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by applicable privacy laws.

I acknowledge receipt of the privacy practices and rights information provided by the Current Provider and acknowledge that I may request an accounting of disclosures made pursuant to this authorization.

Patient initial to indicate acknowledgment:

Additional Instructions / Limitations

Authorization for Release of Records

Patient Name:   Date of Birth:

By signing below I authorize the release and migration of my medical records as specified in this form.

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