Healthcare Partner of Record

HEALTHCARE PARTNER OF RECORD AUTHORIZATION

This Healthcare Partner of Record Authorization designates an external provider, organization, or other authorized entity to receive, exchange, and coordinate protected health information (PHI) with the undersigned patient or the patient's legal representative for treatment, care coordination, and related administrative purposes. Patient Name:

1. Patient Information

2. Designated Healthcare Partner

Entity Type: Individual Provider Organization / Clinic Other

3. Authorization and Scope

I hereby authorize the release, receipt, inspection and exchange of my protected health information between my health care provider(s) and the designated Healthcare Partner of Record identified above. This authorization specifically includes information related to diagnoses, treatment plans, laboratory and imaging results, medication lists, immunizations, care summaries, referral information, and discharge summaries. This authorization does not authorize release of psychotherapy notes unless I check the box below.

Include Psychotherapy Notes: Yes No

Purpose of Disclosure:

4. Limits, Conditions and Re-disclosure

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 laws, except where additional legal protections apply. The Healthcare Partner of Record is directed to use reasonable safeguards to protect PHI and to limit further disclosures to those necessary for the stated purpose. This authorization does not authorize disclosure for marketing or sale of PHI.

5. Medical Information Summary (optional)

6. Insurance Information

7. Acknowledgments and Consent

By signing below, I acknowledge and agree that:

• My authorization is voluntary and I may refuse to sign without affecting my ability to obtain treatment.
• I may revoke this authorization at any time by providing a written revocation to my health care provider, except to the extent that action has already been taken in reliance on this authorization.
• The recipient of PHI may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this authorization, except where allowed by law.
• I understand I have the right to inspect and copy the protected health information described in this authorization, subject to applicable law.

Communicate via electronic means (email, fax, electronic health record messaging) where appropriate: Yes No

8. Expiration and Revocation

This authorization will remain in effect until: unless earlier revoked in writing. To revoke this authorization, send a written revocation to the health information custodian at the address on record.

9. Certification

I certify that I am the patient or the patient's legal representative and that I have authority to execute this authorization. I understand the contents of this form and request the disclosure of the protected health information as described.

Acknowledgment of Privacy Practices: I have received or been offered the Notice of Privacy Practices.

10. Additional Instructions / Limitations

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