Healthcare REACH Agreement

HEALTHCARE REACH AGREEMENT

This Healthcare REACH Agreement ("Agreement") documents the terms under which the Client and the Provider agree that the Client will enroll in, and receive, REACH program services consisting of coordinated outreach, assessment, and health-related support. Client Name: Provider Name:

Program Enrollment Details

Enrollment Date: Participant role:

Patient Information

Emergency Contact

Insurance Information

Medical History

Scope of REACH Services

The Provider will provide the following services as appropriate and agreed upon with the Client. Check all services to be provided:

Care coordination and referrals

Home visits and in-person outreach

Telehealth visits and remote monitoring

Medication review and management support

Consent to Treatment and Care Coordination

By signing this Agreement the Client consents to receive REACH services listed above and authorizes Provider staff to perform assessments, provide health education, coordinate referrals, and communicate with other health care providers, social services, and community partners as necessary for care coordination. The Client acknowledges that participation is voluntary and that consent may be revoked in writing at any time, except to the extent that Provider has already acted in reliance on this consent.

Authorization to Use and Disclose Protected Health Information (PHI)

I authorize the Provider to use and disclose my protected health information as necessary to provide REACH services and coordinate my care. Disclosures may include but are not limited to: medical records, medication lists, social needs assessments, and care plans. The information may be shared with other healthcare providers, payers, community service agencies, and designated family or caregivers to facilitate services.

Authorization Expiration: This authorization will expire on unless an earlier revocation is provided in writing.

I acknowledge that treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing this authorization except where allowed by law. I understand that information disclosed under this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations.

I acknowledge receipt of the Provider's privacy practices and understand my rights with respect to my health information.

I acknowledge I have received and understand the Provider's Notice of Privacy Practices.

Risks, Benefits, and Alternatives

The anticipated benefits of participation include improved care coordination, access to community resources, and assistance with health-related needs. Potential risks include unintended disclosure of personal health information despite reasonable safeguards, and the possibility that recommended services may not produce the expected outcome. Alternative options include receiving care from other providers or declining participation in program components. By signing, the Client acknowledges having discussed risks and benefits with Provider staff and having the opportunity to ask questions.

Client Rights and Responsibilities

The Client has the right to be treated with dignity and respect, to receive clear information about services, to refuse or withdraw consent, and to request restrictions on disclosures of PHI. The Client is responsible for providing complete and accurate information, keeping scheduled appointments when possible, and communicating concerns about care or services.

Liability, Indemnification and Termination

The Provider will exercise reasonable care in the performance of services. To the fullest extent permitted by law, the Client releases and holds the Provider harmless from claims arising from participation in REACH services except for claims arising from gross negligence or willful misconduct. Either party may terminate this Agreement upon written notice; termination does not affect disclosures already made in reliance on a valid authorization.

Acknowledgment and Certification

By signing below, I certify that I have read and understand the terms of this Agreement, that I have had the opportunity to ask questions, and that the information I provided is accurate to the best of my knowledge. I authorize the Provider to contact me and my listed contacts for care coordination and program-related communications.

Sign Now