Healthcare Reporting Package

HEALTHCARE REPORTING PACKAGE

This Healthcare Reporting Package documents patient identification, clinical encounter data, diagnostic and procedural information, relevant attachments, and patient authorization for release of health information. Completion of each section and accurate signature is required to permit disclosure, processing, and continuity of care. All information provided is subject to applicable privacy and confidentiality laws.

Patient Information

Date of Birth:    Gender:

Insurance / Payer Information

Emergency & Referring Provider

Encounter / Clinical Report

Date of service:    Facility:

Encounter type: Inpatient Outpatient Emergency Telehealth

License / NPI:

Vitals

Height:    Weight:    Blood pressure:

Temperature:    Pulse:    Respirations:

Diagnosis & Procedures

Medications & Allergies

Clinical Assessment & Plan

Follow-up instructions / next appointment:

Referral required: Yes No    If yes, refer to:

Attachments Checklist

Lab results
Imaging (radiology, CT, MRI)
Operative report
Pathology report
Medication list
Discharge summary
Other:

Authorization to Release Information / HIPAA Acknowledgment

I hereby authorize the release and disclosure of the patient health information described in this package to the recipient named below for the purpose stated. This authorization includes demographic information, diagnoses, treatment notes, laboratory and imaging reports, medication lists, operative reports, and other records described in the attachments checklist unless specifically excluded in writing. I understand that this information may be used for treatment, payment, healthcare operations, or continuity of care and may be necessary for coordination with other providers or payers.

Expiration: This authorization will expire on or upon completion of the purpose described above, whichever occurs first. 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 upon it. I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations, except where state law provides additional protections.

I acknowledge that I have received the Notice of Privacy Practices and understand my rights regarding my health information. I understand that signing this form is voluntary and that treatment, payment, enrollment, or eligibility for benefits cannot be conditioned on signing this authorization unless allowed by law.

I acknowledge receipt of the privacy practices notice.
I understand the terms of this authorization and consent to disclosure as described.
I request a copy of this authorization be provided to me upon request.

Certification

I certify that the information contained in this Healthcare Reporting Package is true, correct, and complete to the best of my knowledge. I understand that knowingly making false statements regarding medical or insurance information may be subject to legal penalties under applicable law. By signing below I authorize the release of health information as set forth above and attest that I have legal authority to sign this authorization for the patient indicated.

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