OptumCare Hospice Referral

OptumCare Hospice

6262 McPherson Suite 413 Laredo, Texas 78041

Phone: 956-441-1155

Fax: 956-567-9243

Authorization for Use and Disclosures of Health Information

Patient Name

Date of Birth

Date

Last 4 Digits of Social Security Number

Phone Number

I (Printed Name of Patient) authorize(Healthcare Provider) to release protected health information to OptumCare Hospice for the purpose of conducting a hospice evaluation, initiating, continuing and/or adjusting the hospice plan of care.

This authorization for release of information covers the period of healthcare from (select one of the following):

All past, present and future periods; ORFrom (blank) to (blank)

The extent of authorization is as follows (select one of the following):

I authorize the release of my complete health record (including medical records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse); ORI authorize the release of my complete health record with then exception of the following in formation

If selected to authorize health records with exception, which of the following of information is with then exception:

Mental health recordsCommunicable diseases, including medical records relating to mental healthcare, communicable diseases, (HIV or AIDS)Alcohol or drug abuse treatmentOther (please specifiy)

Please send the above information to OptumCare Hospice via fax to: (956) 567-9243

This authorization is valid for a period of two years from the signature date below unless a written notice signed by myself, or by my representative, is received by OptumCare Hospice

OptumCare Hospice has requested consent to photograph me and/or necessary body parts to assist in patient identification, and/or photographic documentation for the hospice plan of care and progression towards established goals. I understand these photographs will only be used as part of my medical record; and the may be shared with other health care providers involved in my care.

Consent to Photograph

I give consent to OptumCare Hospice to take my photographs to be used as stated above.I do not give consent to OptumCare Hospice to take my photographs to be used as stated above.

Notice of Privacy Practices

I acknowledge that I have received information on the "Notice of Privacy Practices" and consent to the agency's use and/or disclosure of protected health information for payment, treatment, continuation of care, and the agency's health care options. The release of this information is necessary to ensure adequate patient care. This consent may be subject to revocation at any time except to the extent that the person or program, which is to make the disclosure, has already acted in reliance on it. Acting in reliance includes the provision of treatment services in a reliance on a valid consent to disclose information to third party payor.

Signature of BeneficiaryAuthorized Agent Relationship

Reason if Patient is Unable to Sign

Agency Representative Signature

Date of Signatures

Date