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343NonDOH March 2011 For persons with disabilities, this document is available on request in other formats. To submit a request, please call 18005250127 (TDD/TTY 18008336388). AUTHORIZATION FOR CARE

How to fill out authorization for care coordination

Point by point guide on how to fill out authorization for care coordination:

1. Begin by obtaining the necessary forms: Contact the healthcare provider or care coordination organization to request the authorization forms. They may provide them online or ask you to visit their office for a physical copy.
2. Read the instructions carefully: Before filling out the forms, carefully read the instructions provided. This will ensure that you understand what information needs to be provided and how to properly complete the authorization.
3. Personal information: The first section of the form typically requires you to provide your personal information. This includes your full name, address, date of birth, contact number, and any other relevant details.
4. Reason for care coordination: Indicate the reason why you are seeking care coordination services. This could be for yourself, a family member, or someone under your care. Provide a brief description of the situation or medical condition that requires coordination.
5. Authorized individuals: If you are granting authorization for someone else to coordinate care on your behalf, provide their full name, relationship to you, and contact information. This will allow healthcare professionals to communicate and share information with the authorized individual.
6. Duration of authorization: Specify the timeframe for which you are granting authorization. This could be an ongoing authorization or a specified period. Ensure that the duration aligns with your needs and preferences.
7. Legal consent: In some authorization forms, there may be a section for providing legal consent. This is where you acknowledge and agree to allow the sharing of your health information for care coordination purposes. Read through this section carefully and sign it if required.
8. Review and submit: Before submitting the completed form, review all the information you have provided to ensure accuracy and completeness. Double-check spellings, contact details, and any supporting documentation that may be required. If everything is in order, submit the form by following the instructions provided.

Who needs authorization for care coordination?

Authorization for care coordination may be required for individuals who:

1. Have complex medical conditions or require care from multiple healthcare providers.
2. Seek assistance in coordinating care with specialists, therapists, or other healthcare professionals.
3. Are transitioning between different healthcare settings, such as hospitals, rehabilitation centers, or home care.
4. Require coordination of services between different healthcare agencies or organizations.
5. Are participating in research studies or clinical trials that involve multiple caregivers and providers.

It is important to note that the need for authorization may vary depending on specific healthcare systems, policies, and individual circumstances. It is always recommended to consult with your healthcare provider or care coordination organization to determine if authorization is necessary in your case.

For pdfFiller’s FAQs

What is authorization for care coordination?

Authorization for care coordination is a process by which a patient gives consent for their healthcare providers to share and coordinate their medical information for the purpose of improving the quality of care.

Who is required to file authorization for care coordination?

Authorization for care coordination is typically filed by the healthcare providers involved in the patient's care, with the patient's consent.

How to fill out authorization for care coordination?

To fill out authorization for care coordination, providers must obtain the patient's consent, clearly outline the purpose of sharing the information, and specify the duration and scope of the authorization.

What is the purpose of authorization for care coordination?

The purpose of authorization for care coordination is to facilitate the exchange of patient information between healthcare providers to ensure comprehensive and coordinated care.

What information must be reported on authorization for care coordination?

The information reported on authorization for care coordination typically includes patient demographic information, medical history, treatment plans, medications, and any other relevant clinical data.

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