Healthcare Neighborhood Services Document

HEALTHCARE NEIGHBORHOOD SERVICES DOCUMENT

Patient Information

Date of Birth:    Gender: Male Female Non-binary Other

Preferred Language:    Interpreter Needed: Yes

Emergency Contact

Insurance Information

Medical History

Neighborhood Services Consent

Description of Services: The Healthcare Neighborhood program provides community-based outreach and care coordination including home visits, telephone follow-up, assistance with appointment scheduling, transportation coordination, referrals to social supports, health education, and limited in-person assistance. These services are intended to support health, housing stability, and access to community resources.

By checking the box below I authorize participation in the Healthcare Neighborhood Services and consent to the specific activities I select. I understand participation is voluntary and that I may refuse or withdraw consent at any time as described below.

Home visits and in-person outreach
Telephone follow-up and care coordination
Assistance arranging transportation
Referrals to social and community services
Health education and resource navigation
Other (specify below)

Risks, Benefits, and Withdrawal

I understand anticipated benefits include improved care coordination, assistance accessing community supports, and improved health follow-up. Potential risks include inadvertent disclosure of personal health information to third parties if I authorize information sharing, and the possible identification of needs that may trigger referrals to mandated services. I understand I may decline any specific service without penalty and may withdraw this consent in writing at any time. Withdrawal does not affect disclosures already made in reliance on this authorization prior to receipt of my written revocation.

I understand and consent

Authorization to Share Health Information

I authorize the release and exchange of my protected health information to support coordination of care between the Healthcare Neighborhood program and the following categories of individuals or organizations as indicated below. This authorization includes relevant clinical records, care plans, medication lists, and social needs assessments to the extent necessary to carry out the authorized services.

Primary care provider / clinic
Specialists and behavioral health providers
Social services and housing agencies
Community-based organizations and case managers
Transportation providers for coordination purposes
Other entities (specify below)

I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy law. Exceptions to confidentiality exist for court orders, reporting of abuse or threats to public safety, and other legal requirements. My care will not be conditioned on signing this authorization unless services are solely for disclosure.

HIPAA Privacy Acknowledgment

I acknowledge that I have been offered a copy of the Notice of Privacy Practices describing how my protected health information may be used and disclosed and my rights under health privacy laws. I understand that the Healthcare Neighborhood program protects health information in accordance with applicable law.

I acknowledge receipt of the Notice of Privacy Practices

Photo / Video and Outreach Communication Consent

I authorize the Healthcare Neighborhood program to take photographs or video of me only as necessary for clinical documentation or service delivery, and not for marketing unless additional written consent is provided. I consent to receiving appointment reminders and program communications by the contact methods listed above unless I opt out.

Consent to photograph/video for clinical documentation
Consent to receive communications (phone/text/email)

Authorization Term and Revocation

This authorization is effective immediately upon my signature and will remain in effect until the earlier of the date specified below or my written revocation delivered to the Healthcare Neighborhood program. I understand that revocation will not affect disclosures already made in reliance on this authorization.

Expiration Date:

Certification

By signing below I certify that I am the patient or am authorized to sign on behalf of the patient. I certify that the information provided on this form is true and accurate to the best of my knowledge, and I authorize the uses and disclosures described above. I understand that I may request a copy of this signed authorization.

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