Healthcare Provider Inquiry Form

HEALTHCARE PROVIDER INQUIRY FORM

Purpose: This form documents a formal inquiry from a healthcare provider or organization requesting information, consultation, care coordination, or transfer of care for a patient. Complete all applicable sections and obtain patient authorization where required. Incomplete forms may delay response.

Requesting Provider / Organization

Patient Information

Patient Name:    Date of Birth:

Relationship:    Phone:

Insurance Information

Nature of Inquiry / Requested Action

Please select all that apply:

Referral/Consultation
Records Request (specify below)
Care Coordination / Shared Care
Appointment Request / Scheduling
Billing / Insurance Inquiry
Other (describe)

Phone    Email    Fax    Secure Portal

Medical History & Current Clinical Information

Authorization & HIPAA Acknowledgment

By signing below, the patient or authorized representative authorizes the disclosure and exchange of protected health information to the requesting provider/organization for the purpose(s) indicated above. This authorization specifically includes copies of medical records, progress notes, laboratory and imaging reports, and billing records as necessary to fulfill the request.

I understand that: (1) the information disclosed may include sensitive information, including behavioral health, substance use treatment, HIV-related information, and genetic information where applicable unless separately restricted by law; (2) I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance on it; and (3) treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing this authorization where prohibited by law.

Authorization expiration date (if no date provided, authorization expires 12 months from signature):

Administrative Use Only

Certification: I certify that the information provided on this form is true and accurate to the best of my knowledge. I authorize the release of the specified health information to the requesting provider or organization for the purposes indicated above and acknowledge my right to revoke this authorization in writing except for actions taken in reliance on this authorization.

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