Healthcare Ongoing Program

HEALTHCARE ONGOING PROGRAM ENROLLMENT & CONSENT

Patient Information

Date of Birth:

Male Female Other / Prefer not to say

Insurance Information

Medical History & Current Health Status

Program Enrollment & Services

Program Name:

Start Date:

Other participating providers or entities authorized to coordinate care:

Risks, Benefits & Patient Rights

I understand that participation in this ongoing program may include clinical assessment, monitoring, medication management, counseling, education, telehealth services, and information exchange among members of my care team. Benefits may include improved disease management, symptom reduction, and care coordination. Risks may include adverse medication effects, emotional distress during treatment, disclosure risks when information is shared for coordination of care, and limits to confidentiality as required by law.

I have the right to ask questions, to decline any part of the program, and to withdraw consent at any time without penalty to my ongoing medical care. Withdrawal of consent will not affect records generated prior to revocation, nor will it affect emergency treatment or disclosures required by law.

Consent to Treatment, Communication & Information Sharing

By signing below I authorize the program and the listed care team members to provide the services described, to exchange relevant medical and billing information with other providers and payors as necessary for treatment and payment, and to use telehealth or electronic communications where appropriate. I authorize the program to leave messages regarding appointments, test results, and care coordination at my primary phone number.

Check all consent items that apply:

I consent to the provision of program services and clinical care by the designated team.
I authorize sharing of my protected health information with the persons and organizations listed above for care coordination and treatment.
I consent to receive telehealth services where clinically appropriate.
I authorize the program to bill my insurer and to disclose information necessary for payment and claims processing.

HIPAA Acknowledgement & Authorization

I acknowledge that I have been offered a copy of the program's Notice of Privacy Practices and that I understand how protected health information about me may be used and disclosed for treatment, payment, and health care operations. I authorize the use and disclosure of my protected health information as necessary for program operations, quality improvement, and care coordination as described above.

This authorization expires on:

I understand that I may revoke this authorization in writing at any time by delivering a written revocation to the program's administrative office. Revocation will not affect disclosures already made in reliance on this authorization prior to receipt of the revocation.

Patient Responsibilities & Program Terms

The patient agrees to attend scheduled appointments, to follow the care plan as discussed with the care team, to notify the program of changes in health status, medications, or insurance, and to provide accurate information. The patient is responsible for co-payments, deductibles, or fees not covered by insurance. Failure to comply with program requirements may result in modification or termination of program services.

Termination: The program may terminate services for noncompliance, failure to pay required fees, safety concerns, or changes in clinical appropriateness. The patient may withdraw at any time by providing written notice.

Additional Authorizations & Notices

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