Healthcare Physician Connect Request

HEALTHCARE PHYSICIAN CONNECT REQUEST

Purpose: Use this form to request that the releasing provider or facility communicate with, consult with, and/or disclose protected health information to the receiving physician or facility listed below for the purposes indicated. Completion of this form authorizes communications and records sharing as described in the Authorization section and is subject to the terms, limitations and revocation rights stated herein.

Patient Information

Insurance Information

Receiving Physician / Facility

Reason for Connect / Requested Action

Purpose (select all that apply):

Information To Be Shared

Check all categories of records and communications you authorize to be shared with the receiving physician or facility.

Scheduling & Communication Preferences

Please indicate whether you want the releasing provider to assist the receiving provider with scheduling an appointment and your preferred timing.

Authorization and Legal Terms

By signing below I authorize the releasing provider, clinic or facility to disclose and discuss my protected health information to the receiving physician/facility identified above for the purposes indicated in this request. This authorization includes verbal communication, electronic transmission, secure messaging, and the release of copies of records.

I understand that records disclosed pursuant to this authorization may include sensitive information such as behavioral health, HIV/AIDS-related information, and substance use disorder treatment records only if I have specifically authorized those categories above. If I have not indicated those categories, such information will be excluded.

I understand that I may revoke this authorization at any time by providing a written revocation to the releasing provider, except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect disclosures already made in reliance on this authorization prior to receipt of the revocation.

This authorization will expire on the date specified below or, if no date is provided, one year from the date of signature, unless otherwise prohibited by law. After disclosure, the receiving entity may re-disclose protected health information and that re-disclosure may no longer be protected by federal privacy rules.

Fees: I acknowledge that the releasing provider may charge a reasonable fee for copying or preparing records, in accordance with applicable law. Any such fees will be communicated to me prior to release when required by law.

Voluntary: I acknowledge that signing this authorization is voluntary and that my refusal to sign will not affect my ability to obtain treatment, payment, enrollment, or eligibility for benefits, except where allowed by law.

HIPAA Acknowledgment

I acknowledge that I have been informed of or provided access to the releasing provider's Notice of Privacy Practices and that I understand the uses and disclosures of my health information described above.

Additional Instructions / Comments

Patient Certification & Signature

I certify that the information provided on this form is true and correct to the best of my knowledge. I authorize the disclosures described above and understand my rights as stated in this authorization.

Notice: A copy of this signed authorization is as valid as the original. Disclosures made pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy law.

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