Health Home Participation Authorization
and Information Sharing Consent
1 Participation Authorization
I, , agree to participate in the Health Home program with
Print name of beneciary Print name of Health Home Lead
Signature of beneciary or beneciary’s legal representative Date
2 Information Sharing Consent
Your health information is private and cannot be given to other people unless you agree or applicable Washington State or
federal laws allow the information to be shared. The providers/partners that can get and see your health information must obey
all these laws. This is true if your health information is on a computer system or on paper. In addition to laws that apply to all
types of health information, specic laws provide greater protection of information related to sexually transmitted diseases, mental
health treatment, and substance use disorder.
I agree that my Health Home can obtain all of my health information from the providers/partners listed on this form to
coordinate my care. I also agree that the Health Home and the providers/partners listed on this form may share my health
information with each other, and other providers/partners involved in managing my care. I understand this form takes the place
of any other Health Home Participation Authorization and Information Sharing Consent forms I may have signed before. I can
change my mind and take back my consent at any time by signing a Health Home Participation-Opt-Out/Decline Services
form and giving it to my Health Home.
PLEASE NOTE: If your health records include any of the following information, you must also complete this section to
include these records.
I give my permission to disclose information about (please put initials next to all that apply):
Mental health HIV/AIDS and STD test results, diagnosis, or treatment
Note: To give consent for the release of condential alcohol or drug treatment information you must complete a separate Release of
form.
Please initial the appropriate choice below.
This consent is valid: as long as my Health Home needs my records for this program; or
until
date or event
I may revoke or withdraw this consent at any time in writing, but that will not aect any information already shared. A
copy of this form provides my permission to share records.
Print name of beneciary Beneciary’s date of birth
Signature of beneciary or beneciary’s legal representative Date
Relationship of legal representative to beneciary
Print name of legal representative (if applicable)
List your providers/partners on page two.
HCA 22-852 (1/22)
Print name of Health Home beneciary
List the name of participating
Past Care Coordination Org. (CCO)/Lead
Past CCO/Lead
Annual consent review date
(MM/DD/YYYY)
Care coordinator name Care coordinator signature
This release of information should include page 1 of the Health Home Participation Authorization and Information Sharing
Consent form in order to provide the legal authority to release information for the beneciary listed above.
Details about the beneciary information sharing and consent process:
1. How will providers/partners use my information?
Providers/partners will use your health information to coordinate and help you manage your health care.
2. Where does my health information come from?
Your health information comes from places and people that gave you health care or health insurance in the past. These may
include hospitals, doctors, pharmacies, laboratories, health plans, the Washington Apple Health (Medicaid) program, and
other groups that share health information. You can get a list of all the places and people by calling your care coordinator.
3. What laws and rules cover how my health information can be shared?
The laws and regulations that protect your health information include Chapter 70.02 RCW in Washington statute, the federal
Health Insurance Portability and Accountability Act (“HIPAA”), and federal regulation 42 CFR Part 2.
4. If I agree, who can obtain and see my information?
Your information may be obtained or seen by the providers/partners you agree can obtain and see it. Information can also
be obtained or seen when allowed by applicable laws. For example, when you get care from a person who is not your usual
doctor or provider, such as a new pharmacy, hospital, or other provider, some information, such as what your health plan pays
for or the name of your Health Home provider, may be given to them or seen by them. For more information on who can get
information, see our Notice of Privacy Practices.
5. What if a person uses my information and I did not agree to let them use it?
If you think a person inappropriately used your information, call your case coordinator or call the HCA Medical Assistance
Customer Service Center (MACSC) toll-free line at 1-800-562-3022 (TRS: 711).
6. How do I make changes to the list of providers/partners on the form?
You can add new names to the list at any time by adding the provider/partner information and lling out the “Beneciary
Gives Consent” columns next to the addition. You can delete someone you no longer wish to include by lling out the
“Beneciary Withdraws Consent” columns next to the previously added provider/partner.
7. What if I change my mind later and want to take back my consent?
You can cancel your consent at any time by signing a Health Home Participation - Opt-Out/Decline Services form and giving
it to your Care Coordinator. You get this form online or by calling the HCA Medical Assistance Customer Service Center
(MACSC) toll-free line at 1-800-562-3022 (TRS: 711). Your care coordinator will help you ll out this form if you want.
Note: If you decide to cancel your consent, providers who already have your information do not have to give your information
back to you or take it out of their records.
8. When do I get a copy of this Health Home Participation Authorization and Information Sharing Consent form?
You can have a copy of the form after you sign it.
