Sample Patient Consent Form

Sample Patient Consent Form
A patient consent form allows us to gather information to share with providers for
the purpose of care management and coordination. The form lists the systems
with whom we connect. We invite you to use the consent form from which to
model your own form. You may want to include the obtaining of claims data to
your form in order to provide pre and post intervention cost data for your patients.
You should speak with your legal team to determine what policies and
procedures are in place to interact with patients, and develop a consent form
ensuring you gain access to the patients’ medical records and claims data.
800 Cooper Street 7th Floor • Camden, NJ • 08102

www.camdenhealth.org • @camdenhealth • 856.365.9510
Camden Coalition of Healthcare Providers
AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH
INFORMATION
I authorize:
Cooper Health System Project H.O.P.E.

Virtua Health System My insurance plan: _________________
Our Lady of Lourdes Health System My provider(s): ____________________
CAMcare Other: ____________________________
To use and disclose a copy of the specific health information described below regarding:
_____________________________________________________________ ___________________________________________
(Name of individual) (Date of Birth)
________________________________________________________________________
(Address of Individual)
________________________________________________________________________
(City, State, Zip Code)
Consisting of:
ü History and physical examinations ü Consultation reports
ü Laboratory reports ü Operative reports
ü Discharge summary ü X-ray/Diagnostic images
ü Bioelectric output (i.e., EKG, EEG) ü Tissue and/or blood specimens
ü Other, specify_______________________________________________
To: Camden Coalition of Healthcare Providers, Attn: Care Management Team

800 Cooper St, 7th floor
Camden, NJ 08102
Phone (856) 365-9510; Fax (856) 365-9520
For the purpose of: Care management and care coordination

If the information to be disclosed contains any of the types of records or information listed below, additional laws relating to the
use and disclosure of the information may apply. I understand and agree that this information will be disclosed only if I place my
INITIALS in the applicable space next to the type of information.
û_____ HIV/AIDS information

û_____ Mental health information
û_____ Genetic testing information
û_____ Drug/alcohol diagnosis, treatment, or referral information
This authorization is voluntary, and you may refuse to sign this authorization. Refusal to sign the authorization will not adversely
affect your ability to receive health care services from your usual providers; however, your refusal to sign this authorization will
affect your ability to participate in this care coordination project.
You may revoke this authorization in writing at any time. If you revoke your authorization, the information described above may
no longer be used or disclosed for the purposes described in this written authorization. Any uses or disclosures already made with
your permission cannot be undone.

I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure and no longer be
protected under federal law. However, I also understand that federal or state law may restrict re-disclosure of HIV/AIDS
information, mental health information, genetic information and drug/alcohol diagnosis, treatment or referral information.
I understand that my health information may be shared with health care providers, social workers, nurse case managers, health
lawyers, community agencies, and other professionals who have been, are currently, or will be involved in my care in order to
better coordinate my care.
I have read this authorization and I understand it.

Unless revoked, this authorization does not expire.
By:û _________________________________________________________ Date: ______________
(Signature of individual or Legally Authorized Representative)
Description of relationship to individual: ________________________________________________


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Sample Patient Consent Form

800 Cooper Street 7th Floor • Camden, NJ • 08102

Cooper Health System Project H.O.P.E.

To: Camden Coalition of Healthcare Providers, Attn: Care Management Team

For the purpose of: Care management and care coordination

û_____ HIV/AIDS information

800 Cooper Street 7th Floor • Camden, NJ • 08102

I have read this authorization and I understand it.

Description of relationship to individual: ________________________________________________

800 Cooper Street 7th Floor • Camden, NJ • 08102

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