Nebraska RHT Patient Authorization & Consent Form

Nebraska RHT Patient Authorization & Consent Form

Complete this form to authorize participation, sharing, and use of health information in accordance with HIPAA and applicable laws.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Contact Phone Number we can call/text monthly*
Please enter a valid phone number.
Email Address*
example@example.com
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Primary Language Spoken*
Do you require translation or interpreter services?*

YesNo
Preferred Method of Contact*

Phone CallText MessageEmailMail
Primary Pharmacy Information
Pharmacy Name
Pharmacy NPI (ask pharmacy team member if you do not know)
Primary Provider Information
Name of Provider
Address of Primary Provider
Insurance Information

Enter your current insurance and pharmacy benefit information.
Insurance Carrier Name*
Insurance Member ID*
Group Number
Policyholder Name

First NameLast Name
Pharmacy Benefit Manager (PBM)
Rx BIN
Rx PCN
Rx Group
Upload Health Insurance Card (Front)

Cancelof
Upload Health Insurance Card (Back)

Cancelof
Upload Pharmacy Card (Front)

Cancelof
Upload Pharmacy Card (Back)

Cancelof
Authorization to Participate in the following Service Options- check all that you would like: Med adherence: Med sync, app download, packaging, delivery, lab reporting, blood pressure monitoring ::Maternal care includes screenings and monthly blood pressure monitoring.*

Medication Adherence if eligibleMaternal Health Screening if eligibleOther
HIPAA Authorization for Use & Disclosure of Protected Health Information (PHI)*

I authorize use and disclosure of my health information as described in this form.
Authorization to Access Health & Cost Data*

I authorize access to my health and cost data from January 2025 until 6 months post services for coordination and payment of services.I authorize communication with my primary provider with all of my healthcare, labs and pharmacy medication.
Patient Rights & Acknowledgments*

I understand my rights regarding this authorization, including the right to revoke and to receive a copy.I acknowledge that I have received and reviewed the HIPAA Notice of Privacy Practices.I understand I am authorizing services at no charge to me for the duration of the funding for current RHT program
Signature of Patient or Personal Representative (type name)*

First NameLast Name
Relationship to Patient (if not self)
Signature (Patient or Representative)*

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Date Signed*

MonthDayYear
Date
Witness Signature

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Staff Receiving Information (name)
Should be Empty:

Nebraska RHT Patient Authorization & Consent Form

Primary Pharmacy Information

Primary Provider Information

Insurance Information