Healthcare Opt In Letter

HEALTHCARE OPT IN LETTER

Clinic/Practice Name:   Location/Department:

Patient Information

Date of Birth:   Gender: Female Male Other / Prefer not to say

Phone:   Email:

Insurance Information

Policy Number:   Group Number:

Medical History (summary)

Opt-In Selections & Authorization

By signing below, I voluntarily authorize the uses and disclosures of my protected health information as indicated. I understand that checking options constitutes specific consent for each purpose listed.

I consent to receive communications related to treatment, appointment reminders and clinical care coordination.

I consent to disclosures necessary for billing and payment processing.

I consent to uses for healthcare operations including quality assessment, care management, and administrative tasks.

I consent to limited use of my de-identified or identified information for research purposes as permitted by law. I understand I may refuse this authorization without affecting my treatment.

I consent to receive marketing communications and appointment reminders via telephone, SMS/text messages, and email. I understand message/data rates may apply.

I authorize disclosure of my health information to family members or designated persons for purposes of care coordination. If checked, designate name(s) below.

Types of Information Covered

The following categories of information may be used or disclosed if selected:

Medical records, progress notes, diagnoses and treatment plans

Laboratory and pathology results

Radiology and imaging reports

Billing and insurance information

Appointment and scheduling history

Authorization Terms — Important Legal Notices

Purpose: The information authorized for use or disclosure will be used for the purposes I selected above. This authorization is voluntary and is not a condition of receiving treatment, payment, enrollment, or eligibility for benefits unless allowed by law.

Redisclosure: 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.

Right to Revoke: I may revoke this authorization at any time by delivering a written notice to the practice, except to the extent action has already been taken in reliance on this authorization. Revocation does not affect disclosures made prior to receipt of revocation.

Expiration: Unless otherwise revoked, this authorization will expire on: . If no date is entered, this authorization will expire one year from the date of signature.

Conditions and Limitations: I understand that I may inspect or copy the protected health information described on this form and that I may refuse to sign this authorization. I understand that treatment, payment, enrollment, or eligibility for benefits may not be conditioned on my signing this authorization except where permitted by law.

I acknowledge receipt of the facility's Notice of Privacy Practices and understand how my information will be used and disclosed under this authorization. I understand the risks and benefits of consenting to the uses and disclosures described above.

I acknowledge that I have read and understand the terms of this authorization.

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