Healthcare UDS Form

Healthcare UDS Form

This form collects patient-level demographic, clinical, and insurance data necessary for Uniform Data System (UDS) reporting and quality improvement. Information provided will be used for clinical care, program administration, and aggregate reporting. By completing and signing, the patient certifies the information is true and authorizes release of necessary data for healthcare operations and mandated reporting consistent with applicable privacy protections.

Patient Information

Emergency Contact

Demographic Data (UDS)

Race (select all that apply):
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other (specify):

Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Decline to state

Veteran Status: Yes No Decline

Insurance and Financial

Insurance Type: Medicaid Medicare Private Uninsured

Medical History

Tobacco Use: Current Former Never

Pregnancy Status (if applicable): Pregnant Not Pregnant Unknown

Clinical Measurements

Visit and Services

Date of Visit:

Visit Type: New Patient Established Preventive Chronic Care

Authorization, Consent, and Certification

I hereby consent to the provision of medical care and necessary services by the facility and its authorized clinicians. I authorize release of my health information to the facility's administrative staff and to authorized entities for the purpose of clinical care, billing, and required reporting, including data aggregation for Uniform Data System reporting. I understand that such disclosures are subject to applicable privacy protections and that reported data will be used in aggregate without direct personal identifiers for program evaluation and compliance.

I acknowledge that the information provided on this form is complete and accurate to the best of my knowledge. I understand that deliberate falsification of information may result in ineligibility for certain programs or may be subject to penalties under applicable law.

This authorization to disclose health information for reporting purposes expires on:

HIPAA Privacy Notice Acknowledgment: I acknowledge that I have been provided information regarding my privacy rights and the facility's privacy practices.

Consent for Release of Information for UDS Reporting: I consent to necessary release of de-identified and limited-identifiable health information for the purposes of Uniform Data System reporting as required by program regulations.

Clinical Quality / Screening Items (if applicable)

Attestation

By signing below, I attest that I am the patient or the authorized representative of the patient and that the information provided on this form is true and correct. I understand that the facility will maintain this information in my medical record and may use or disclose it as described above.

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