Healthcare Provider List Update

HEALTHCARE PROVIDER LIST UPDATE

Patient Information

Patient Name:

Date of Birth:

Update Details

Effective Date of Update:

Reason for update (select all that apply):

New provider Discontinue care Insurance change Other

Provider List (Add / Remove / Update)

Enter the providers to be added, removed, or updated. Provide as much identifying information as possible to ensure accurate record sharing and referrals.

If you need additional provider entries, attach a signed and dated continuation sheet containing the same details for each additional provider.

Insurance Information

Medical Information

Current Medications (include dosage and frequency)

Allergies (include medication and environmental)

Prior Surgeries / Hospitalizations (include year and reason)

Chronic Conditions / Active Diagnoses

Authorization and Consent

I authorize the release and exchange of my protected health information between the healthcare organization that maintains my records and the providers listed above for the purpose of coordinating care, referrals, claims processing, and continuity of treatment. This authorization includes past, present and future medical records, diagnostic reports, medication lists, and any other information necessary to carry out the purposes stated herein.

I understand that (a) I may revoke this authorization at any time by submitting a signed, written revocation to the health information management office; (b) revocation will not apply to disclosures already made in reliance on this authorization; and (c) information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations.

Acknowledgment: I hereby authorize the release described above

Authorization Expiration Date:

Certification

By signing below I certify that the information I have provided on this Healthcare Provider List Update is true and correct to the best of my knowledge. I authorize the healthcare organization to verify provider identifiers and contact information as necessary. I understand that false statements may be subject to penalties under applicable law.

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