Healthcare Supportive Services Form

Healthcare Supportive Services Form

Purpose: This form documents the patient’s request for and authorization of non-clinical and supportive services intended to assist with activities of daily living, care coordination, transportation, counseling, and other community-based supports. Completion of this form authorizes the release and exchange of protected health information as necessary to arrange, coordinate, and evaluate the requested supportive services.

Patient Information

Date of Birth:    Gender: Female Male Other Decline to state

Emergency Contact

Insurance Information

Supportive Services Requested

Please indicate requested services (check all that apply):

Case management Care coordination Home health aide / personal care Transportation assistance

Nutrition / meal support Mental health counseling Medication management Durable medical equipment

Desired start date:    Service frequency: One-time Weekly Monthly As needed

Medical History & Needs

Consent to Exchange Information & Authorization

I authorize my healthcare providers, support service agencies, payers, and authorized representatives to disclose and exchange my protected health information (PHI) as needed to arrange, provide, coordinate, and evaluate the supportive services I have requested, including but not limited to care plans, medication information, functional status, pertinent medical history, and billing information. This authorization includes verbal and written exchanges and transmission by electronic means where applicable.

Purpose: Coordination of supportive services; eligibility determination; billing and payment; service planning and follow-up.

I understand that I may revoke this authorization at any time by providing written notice to the organization coordinating services, except to the extent that action has already been taken in reliance on this authorization. This authorization expires on:

I understand that treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing this authorization except where applicable to payment for services requested. I also 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.

I consent to receiving appointment reminders, care coordination communications, and service notifications at the phone number and/or email provided above: Calls/SMS Email

Privacy Notice Acknowledgment

I acknowledge that I have been offered information about privacy practices that describe how my health information may be used and disclosed and how I can exercise my privacy rights. I understand that I may request restrictions on certain uses and disclosures and that requests will be evaluated in accordance with applicable law.

I acknowledge receipt of the privacy notice or have been offered a copy.

Risks, Benefits and Voluntary Consent

I understand the nature of the requested supportive services, foreseeable benefits, and potential risks or limitations including, but not limited to, variable availability of services, transportation risks, and limitations of non-clinical supports. I understand that services are intended to support independent living and that I may withdraw consent at any time by providing written notice as described above.

By signing below I certify that the information provided is true and accurate to the best of my knowledge and that I authorize the release and exchange of information as stated in this form for the purposes described herein.

Certification: I certify under penalty of law that I am authorized to request and receive the services indicated on this form and that the information provided is accurate. I understand that falsifying information may result in denial of services and potential legal consequences.

Sign Now