Healthcare Outreach Center

HEALTHCARE OUTREACH CENTER — PATIENT INTAKE, CONSENT & AUTHORIZATION

Center Identification

Facility:   Program/Clinic Location:

Patient Information

Female    Male    Non-binary/Other    Prefer not to say

Emergency Contact

Insurance Information

Medical History (Relevant to Outreach Services)

Outreach Program Consent — Description, Risks, Benefits

Description of Services: I consent to participate in Healthcare Outreach Center activities including screening, education, referral, case management, vaccinations, and limited clinical procedures performed in outreach settings. These services are intended to identify needs, coordinate care, and connect patients with follow-up services.

Risks and Benefits: I acknowledge that benefits may include early detection of conditions, referral to treatment, and improved access to care. Risks may include temporary discomfort, potential for privacy breaches associated with communications and records, and the limitations of care provided in an outreach environment. I understand staff will minimize risks and maintain confidentiality consistent with applicable law.

Voluntary Participation and Right to Withdraw: Participation is voluntary. I may decline services or withdraw this consent at any time. Withdrawal will not affect my right to future services, except to the extent that action has already been taken in reliance on this authorization.

Authorization to Use and Disclose Protected Health Information (PHI)

Authorization: I authorize Healthcare Outreach Center and its authorized agents to use and disclose my protected health information for purposes of care coordination, outreach follow-up, referrals, care navigation, program evaluation, and billing related to services provided. This authorization specifically includes disclosure of: medical records relating to diagnoses and treatment; medication lists; immunization and vaccination records; appointment history; case management notes; and contact information.

Recipients: Disclosures may be made to other health care providers, referral partners, community agencies, payors, and agents engaged by the Outreach Center to facilitate my care. I understand information will be limited to the minimum necessary for the intended purpose.

Treatment records    Medication history    Immunizations
Case management notes    Contact information and appointment history

Revocation: I understand I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance on this authorization. To revoke, I must provide written notice to the Outreach Center at the location identified above.

Communications & Contact Preferences

I consent to being contacted by Healthcare Outreach Center by the methods I select below. I understand that communications may include appointment reminders, care coordination, referrals, program updates, and follow-ups. I understand that text messages or voicemail may contain limited health information and that standard messaging rates may apply.

Phone calls    Text messages (SMS)    Email    Postal mail

Yes    No

I consent to limited use of photographs/video that do not reveal my identity    I do not consent

Privacy Acknowledgment

Notice: The Outreach Center maintains confidentiality and will protect your health information in accordance with applicable law. This authorization is separate from any general notice of privacy practices and is specific to the release and use of information described above.

Patient Certification

By signing below I certify that I am the patient or am legally authorized to act on behalf of the patient. I have read (or have had read to me) the information on this form, and I understand the uses and disclosures described. I authorize the Outreach Center to provide the services described and to use and disclose my protected health information consistent with this authorization.

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