Fillable Form Hcp-Cda-02 - Hipaa Contact Disclosure printable pdf download

HIPAA CONTACT DISCLOSURE

I,____________________________ (DOB)_____________, give Dr.______________________

and staff, authorization to disclose my protected health information to the following family, friends and/or

caregivers:

Name:__________________________________Relationship:______________Phone:______________

In the event HealthCare Partners of Nevada may need to give your test results or medical

information, may we………(check all that apply)

_____ Leave a detailed voice message on this phone, the number is ______________________.

_____ Call you on your cellular phone, the number is_____________________

_____ Call you at work, the number is_________________________________

_____ Speak to you directly. ONLY

Disclaimer: Certain Sensitive health information (treatment / testing) are specifically protected and will

not be disclosed outside of the clinic setting without specific authorization. This includes the following:

• Mental / behavioral Health records

• Sexually transmitted disease (STD)

• Alcohol / drug dependency treatment

• Genetic testing / test results

• HIV testing results / AIDS treatment

Please indicate if you allow or deny HealthCare Partners the ability to share this information with

you, per the indicated communication option above.

I allow HealthCare Partners to share sensitive health information as noted above per the communication

options checked on this form. __________________________ (Patient Signature)

I DO NOT allow HealthCare Partners to share sensitive health information as noted above.

__________________________ (Patient Signature)

I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this

authorization I must do so in writing and present my written revocation to Medical Records department.

I understand that the revocation will not apply to information that has already been released in response to

this authorization. I understand that the revocation will not apply to information shared in the process of

treatment, payment or healthcare operations as sighted in the Notice of Privacy Practices.

I understand that authorizing the disclosure of this health information is voluntary. HealthCare Partners

and its entities will not condition treatment, payment, enrollment or eligibility for benefits on providing,

or refusing to provide this authorization. I understand that any disclosure of information carries with it

the potential for an unauthorized re-disclosure and the information may not be protected by Federal

Confidentiality Rules. If I have questions about the disclosure of my health information, I can refer to

my Notice of Privacy Practices, which I obtained from my doctor’s office.

Unless, otherwise revoked, this authorization will expire on the following date, event or condition:

____________________________________________________________________________________

If I fail to specify a date this authorization will expire one (1) year from the signature on this

form.

_____________________________________________Date___________________________

Signature of Patient

_____________________________________________Date___________________________

Signature of Guardian or Personal Representative

_____________________________________________Date__________________________

Signature of HealthCare Partners of Nevada Employee

Form No. HCP-CDA-02

Revised 7/2016

Form Hcp-Cda-02 - Hipaa Contact Disclosure

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