Care Coordination Services — Patient Enrollment & HIPAA Authorization

Care Coordination Services — Patient Enrollment & HIPAA Authorization

Enroll for care coordination services and authorize HIPAA-compliant information sharing.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
State
Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Programs of Interest
Current Medications (optional)
Preferred Contact Method
Best Time to Contact
HIPAA Authorization
I authorize Care Coordination Services (carecoordination-services.com) and its representatives to use and disclose my health information as necessary to provide care coordination services, including but not limited to Prescription Savings, Chronic Care Management, Annual Wellness Visits, and Medical Alert System coordination. I understand that my information will be handled in compliance with HIPAA regulations and that I may revoke this authorization at any time by contacting Care Coordination Services in writing.
E-Signature
I have read and agree to the HIPAA Authorization above.
I confirm that all information provided is accurate and I am 18 years of age or older.
Should be Empty: