Healthcare MOC Form

HEALTHCARE MOC FORM

Patient Information

Patient Name:    Date of Birth:    Medical Record #:

Insurance Information

Medical History & Current Status

Management of Care (MOC) — Plan Overview

Reason for initiation of MOC:

Anticipated duration of this plan:    Start Date:

Risks, Benefits, and Alternatives

The treating clinician has explained the nature of the recommended ongoing care, expected benefits, material risks, and reasonable alternatives including no treatment. I acknowledge that no outcome is guaranteed and that complications may occur.

I acknowledge the following (check each to indicate understanding and consent):

I have received an explanation of the risks and benefits of the proposed ongoing care and have had the opportunity to ask questions.

I have been informed of reasonable alternatives to the recommended plan, including the option of not initiating or discontinuing treatment.

I accept financial responsibility for services rendered according to the provider's billing policies and my insurance coverage.

Information Sharing & HIPAA Authorization

I authorize the disclosure of my protected health information to other members of the care team and to authorized agents for the purposes of care coordination, payment, and quality assurance as described below. This authorization includes diagnosis, treatment records, medication information, and relevant test results. I understand that my information will be handled consistent with applicable privacy laws and that I may revoke this authorization as described below.

I consent to release health information to other providers, case managers, and payers for coordination of care.

Revocation: I understand that I may revoke this authorization at any time by delivering a written notice to the providing facility or clinician, except to the extent that action has already been taken in reliance on this authorization.

Certification and Attestation

By signing below I certify that the information I have provided on this form is accurate to the best of my knowledge. I authorize the treating clinicians to implement the described Management of Care plan. I acknowledge that I have had the opportunity to ask questions and that those questions were answered to my satisfaction. I understand I may withdraw consent for parts of the plan except where doing so would create immediate risk to my health.

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