Healthcare PECA UMA

HEALTHCARE PECA UMA

This Patient Electronic Communications and Utilization Management Authorization (PECA UMA) documents the patient’s informed consent and authorization for electronic communications, disclosure, and limited access to protected health information for purposes of utilization management, care coordination, and administrative processing. Patient Name: Date of Birth:

Patient Information

Gender (select applicable): Male Female Other

Insurance Information

Medical History & Current Condition

Authorization: Electronic Communications & UMA Access

I authorize the health care provider and its agents to communicate with me and to disclose my protected health information (PHI) as necessary for utilization management, prior authorization, discharge planning, coordination of care, billing, and administrative functions. This authorization includes electronic communications (email, text messaging, patient portal) and transfer of PHI to utilization management agents. I specifically authorize:

- Exchange of medical records, clinical summaries, and utilization review documentation with utilization management entities: Yes

I understand that electronic communications may not be completely secure and may involve risks of unauthorized access or interception. I accept these risks and consent to receiving communications at the contact information provided above. I acknowledge that the provider will take reasonable measures to protect confidentiality but cannot guarantee absolute security.

HIPAA Authorization & Redisclosure

I authorize disclosure of my PHI as described in this form in accordance with applicable privacy laws. I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by privacy laws. The provider is not responsible for redisclosure by third parties.

Purpose(s) of disclosure: utilization management, care coordination, insurance review, claims adjudication, quality assurance, and related administrative activities. Purpose(s):

Duration, Revocation, and Rights

This authorization is effective on the date signed and will expire on: . I understand I may revoke this authorization at any time by providing a written notice to the provider, except to the extent that the provider has acted in reliance on this authorization prior to such revocation.

I understand that treatment, payment, enrollment, or eligibility for benefits will not be conditioned on my signing this authorization except where permitted by law for certain services. By signing below I certify that I have read and understand this authorization and that it has been explained to me.

Patient Attestation

By signing, I attest that I am the patient or I am authorized to act on behalf of the patient as a personal representative. Relationship to patient (if signing as representative):

Certification: I understand that false statements on this form may be subject to penalties under applicable law. I further certify that the information I have provided is true and correct to the best of my knowledge.

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