Healthcare Primary Care Roles

HEALTHCARE PRIMARY CARE ROLES

Patient Information

Date of Birth:    Gender:

Primary Phone:    Email:

Relationship:    Phone:

Insurance Information

Policy Number:    Group Number:

Primary Care Provider / Practice

Office Phone:    Office Address:

Assigned Roles and Delegations

Select the primary care roles and delegations to be performed by the PCP and the primary care team. A checked box constitutes delegation and authorization consistent with applicable law and scope of practice.

Primary Medical Provider (ongoing comprehensive care)
Care Coordination and Case Management
Chronic Disease Management (e.g., diabetes, hypertension)
Medication Reconciliation and Management
Preventive Care and Health Maintenance
Referral Management to Specialists
After-Hours Access and Urgent Advice
Behavioral Health Coordination
Telehealth Services as appropriate

Scope, Effective Period, and Limitations

Effective Date:    Authorization Expires:

The primary care roles described in this document authorize the named PCP and designated care team members to perform the identified clinical functions within the limits of applicable state law, professional scope of practice, and the policies of the practice. This authorization does not obligate the PCP to perform functions beyond those enabled by licensure and credentialing, nor does it transfer legal responsibility for non-delegable clinical judgments.

Patient Responsibilities and Acknowledgments

By signing below, the patient acknowledges and agrees to the following responsibilities associated with primary care management:

Keep scheduled appointments and notify office of cancellations in a timely manner.
Provide accurate and complete medical history, including medications and allergies.
Follow recommended treatment plans and medication regimens, and ask questions when unclear.
Notify the practice of changes in insurance, address, or emergency contact details.

Authorization to Share Health Information

I authorize the primary care provider and the primary care team to access, use and disclose my protected health information to other health care providers, care coordinators, and payers as necessary to provide coordinated care, referrals, and care management. This authorization includes exchange of information through secure electronic health records and communications consistent with privacy laws.

I authorize the sharing of my health information as described above.

HIPAA Privacy Acknowledgment

I acknowledge that I have been offered or received the practice's Notice of Privacy Practices describing how my protected health information may be used and disclosed, and my rights under applicable privacy laws.

I acknowledge receipt of the Notice of Privacy Practices.

Revocation and Termination

This authorization is valid for the period stated above unless revoked earlier. I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it. To revoke, deliver a written notice to the practice named in this document. Termination of this authorization does not affect actions taken prior to revocation.

Limitations of Liability and Administrative Provisions

The practice and PCP will exercise reasonable care in coordinating services. The practice is not liable for acts or omissions of third-party specialists or outside entities. Nothing in this document limits any rights the patient has under applicable law. Disputes regarding clinical care will be managed according to the practice's complaint and grievance procedures.

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