Healthcare Resource Guide

HEALTHCARE RESOURCE GUIDE

This Healthcare Resource Guide is provided to assist patients in identifying clinical, social, and community resources relevant to medical care and social needs. The information contained herein is for informational purposes only and is not a guarantee of availability, eligibility, or outcome. The patient may authorize limited disclosure of contact and clinical information to listed resources for the purpose of care coordination; such authorizations must be explicitly indicated below. The organization that provides this Guide does not assume liability for the services or advice of third-party resources.

Patient Information

Patient Name:    Date of Birth:    Gender:

Insurance Information

Medical History

Resource Needs Assessment

Please indicate services you are seeking (check all that apply):

Primary medical care
Behavioral health / counseling
Medication assistance / pharmacy support
Transportation to appointments
Financial assistance for care or medication
Housing or shelter resources
Interpreter or language access services
Home health / visiting nurse
Legal or advocacy services
Other (describe below)

Resource Directory (Selected Contacts)

Use the fields below to record contact details for recommended resources. Staff may complete these fields during care coordination.

Consent to Contact Resources and Information Sharing

The patient may authorize staff to contact listed resources for the purpose of scheduling, referral, or care coordination. Authorizations below are voluntary and may be revoked in writing at any time. When authorized, only the minimum necessary information will be shared consistent with applicable privacy requirements.

I authorize clinic staff to contact resources listed above on my behalf for referral and care coordination.
I authorize sharing limited health information (e.g., diagnosis, medication, appointment needs) with contacted resources as necessary for coordination.
I consent to receive appointment reminders and care messages via text message or automated call (carrier rates may apply).

Privacy and Acknowledgment

By signing below, the patient acknowledges receipt of this Healthcare Resource Guide and understands that: (1) the Guide is informational only; (2) any consent to contact or share information is voluntary and may be revoked in writing; (3) only the minimum necessary information will be shared with resources when permitted; and (4) the organization providing this Guide is not responsible for the actions, services, or quality of care provided by third-party resources.

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