Health Passport Consent
Nombre de Miembro:
Fecha de Nacimiento:
AHCCCS ID:
CIS ID:
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___ /
__
Direccion:
Yo, o mi Representante Autorizado, le autoriza a los proveedores, agencias, y planes de salud contratados con la organización
de Cenpatico Integrated Care que compartan mi información de salud en la aplicación de Cenpatico Integrated Care Health
Passport para ayudar en las operaciones de mi tratamiento, pago, y atención médica. En acuerdo con la ley estatal del estado
de Arizona, la Regla de Privacidad de la Ley de Responsabilidad de 1996 (HIPAA) transferencia de seguros médicos, y 42 CFR
Parte 2, yo entiendo lo siguiente:
1. Consentimiento Voluntario: En firmar este documento, yo consento que esto a mi decision voluntaria. Mi tratamiento,
pago, inscripcion en un plan de salud, o eligibilidad para beneficios no seran determinados de mi consentimiento de este
proverbio.
2. Divulgacion: Informacion revelada a un tercer partido bajo este consentimiento no podra ser protegido bajo la ley estatal
o federal y podria volver a ser revelada por el recipiente con las siguientes excepciones: Si yo, autorizo la publicacion
relacionada a alcohol/drogas, enfermedades transmisibles (incluido VIH / SIDA), las pruebas genéticas (y la información
derivada de la misma), o expedientes o registros de pagos médicos, el destinatario está prohibido volver a revelar la
información sin mi autorización, a menos que se lo permita la ley federal o estatal. Vea 42 CFR Parte 2, A.R.S. § 36-664 (G),
A.R.S § 12-2802 (F), y A.R.S. § 12-2294 (E).
3. Revocacion: Yo tengo el derecho de revocar este consentimiento, con la excepcion en cual la accion ya ha sido tomada
sobre la base de este consentimiento. Debo enviar cualquier revocacion por escrito a la atencion de Cenpatico Integrated
Care en el 333 E. Wetmore, Tucson, AZ 85705 – Atencion Especialista de Privacidad.
La Red de Salud de Cenpatico tendrá acceso bajo la aplicación de Health Passport a mi expediente médico, incluyendo la
historia del paciente, notes de la oficina (excluyendo notas de psicoterapia), referencias, consultas, registros de facturación,
registros de seguranza, y registros enviados a mí por otros proveedores de salud.
El intercambio de información relacionada con el abuso de alcohol / drogas, tratamiento de salud mental (excepto las notas de
psicoterapia), información sobre enfermedades contagiosas (incluyendo el VIH / SIDA), y las pruebas genéticas (y la
información procedida de ella) requiere autorización específica. Al colocar mis iniciales en la línea correspondiente (s) a
continuación, autorizo específicamente la puesta en común de estas categorías de información:
_______ Alcohol/Registros de Drogas
_______ Pruebas Genéticas o Información
Relacionada
_______ Enfermedades Contagiosas (incluyendo el VIH / SIDA)
_______ Tratamiento de Salud Mental (excepto notas de psicoterapia)
NOTA: Las notas de psicoterapia requieren un formulario de autorización por
separado.
A menos que sea revocada, esta autorización sera válida hasta que sea dado de baja de su tratamiento, y
a menos que allá especificado otra fecha aquí:
_____ /
_____ /
_______
Firma (Miembro o Represéntate Autorizado*).
Date
* Si ha firmado por alguien que no sea miembro, por favor especifique su autoridad al firmar y presente documentación.
Usted tendrá derecho de obtener una copia de esta autorización después de que allá firmado. La forma debería ser enviada
a través de fax al (800) 733-9903
Health Passport Consent
Agencies and Health Plans:
Cenpatico Network Of Care
101 WALL SUPPORT SRVCS
LA PAZ COUNSELING SERVICES PLLC
1ST CARE MED CLINIC LLC
LA PAZ REGIONAL HOSPITAL
A NEW LEAF
LATEEF BEHAVIORAL CARE HOMES LLC
A PLUS PHYSICAL THERAPY
LAURA K SCHROEDER MD PC
ABC NEUROLOGY PLLC
LINCARE INC
ABUNDANT HEALTH FAMILY PRACTICE
LUMINARIA LLC
ACHIEVE HUMAN SERVICES
MARANA HEALTH CENTER INC
ADULT GASTROENTEROLOGY PLLC
MARCHAND OBGYN PLLC
ADVANCED MEDICAL LAB
MARIPOSA COMMUNITY HEALTH CENTER
ADVANCED NEURO AND DIAGN
MARTHA L REYES MD
ADVANCED PEDIATRIC CARDIOLOGY PLLC
MEDICAL DIAGNOSTIC LABORATORIES
AJAY NARWANI MD PLLC DBA SPECIALTY PAIN MANAGEMENT
MENTALLY III KIDS IN DISTRESS
ALLEN FAMILY MEDICINE
MESA VERDE MEDICAL GROUP
ALLERGY ASSOCIATES OF TUCSON
MIGUEL A ARENAS
APRIA HEALTHCARE LLC
MINGUS MEDICAL CARE PLLC
ARISTA IMAGING LLC
MIRASOL INC
ARIZONA ADVANCED UROLOG
MT GRAHAM REGIONAL MEDICAL CENTER
ARIZONA COUNSELING & TREATMENT SERVICES
MY DOCTOR NOW
ARIZONA INSTITUTE OF NEUROLOGY AND
POLYSOMNOGRAPHY
ARIZONA MEDICAL SERVICES
NALINI BHALLA MD PLLC
NATIONAL ALLIANCE FOR THE MENTALLY ILL OF SOUTHERN
AZ
ARIZONA MEDICAL TRANSPORT LLC
NATIVE AMERICAN CONNECTIONS
ARIZONA ONCOLOGY ASSOCIATES
NAZCARE INC
ARIZONA UROLOGY CENTER
NEUROPSYCHOLOGY LTD
ARIZONAS CHILDREN ASSOCIATION
NEW HOPE BEHAVIORAL HEALTH
ASHLEY B HART II
NEXTCARE ARIZONA LLC DBA
ASSURANCE HEALTH & WELLNESS
NOBLE CARE CORPORATION
AURORA BEHAVIORAL HEALTH
NORTH COCHISE COMM HOSP
AURORA BEHAVIORAL HEALTHCARE TEMPE LLC
NORTHWEST ALLIED PHYSICIANS LLC
AVALON CARE CENTER TUCSON
NORTHWEST CARDIOLOGY LLC
AZ KIDNEY DISEASE HYPERT
NURSEWISE LP
AZ TECH RADIOLOGY AND OPEN MRI
OLD PUEBLO COMMUNITY SERVICES
BANNER ALZHEIMERS INSTITUTE
OLD PUEBLO HEALTHCARE LL
BANNER BAYWOOD MEDICAL CENTER
OUR FAMILY SERVICES INC
BANNER BEHAVIORAL HEALTH
PAGE HOSPITAL
BANNER BOSWELL MEDICAL CENTER
PALO VERDE HOMECARE LLC
BANNER CANCER CENTER SPECIALISTS LLC
PARK PLACE OUTREACH
BANNER CASA GRANDE MEDICAL CENTER
PARKER FAMILY PRACTICE
BANNER CHILDRENS BANNER
PASADERA BEHAVIORAL HEALTH NETWORK INC
BANNER DEL WEBB MEDICAL CENTER
PATHWAYS OF ARIZONA
BANNER DESERT MEDICAL CENTER
PAUL B MCMASTER DPM
BANNER DESERT SURGERY CENTER
PETER M MYSKIW DPM
BANNER ESTRELLA MEDICAL CENTER
PHOENICIAN MEDICAL CENTER INC
Health Passport Consent
Cenpatico Network Of Care
BANNER ESTRELLA SURGERY CENTER
PHYSICIANS PHYSICAL THER
BANNER GATEWAY MEDICAL CENTER
PIMA HEART PHYSICIANS
BANNER GOLDFIELD MED CTR
PIMA PREVENTION PARTNERS
BANNER GOOD SAM BH CTR
PINAL HISPANIC COUNCIL
BANNER GOOD SAMARITAN MEDICAL CENTER
PINNACLE HEALTHCARE LLC
BANNER HEART HOSPITAL
PORTABLE PRACTICAL EDUCATIONAL PREPARATION INC
BANNER HOME CARE ARIZONA
PRECISION PHYSICAL THERAPY LLC
BANNER HOSP BASED PHYSICANS ARIZONA LLC
PREFERRED HEALTH INC
BANNER IRONWOOD MEDICAL CENTER
PRESBYTERIAN SERVICE AGENCY
BANNER PHYSICIAN SPECIALISTS ARIZONA LLC
PRN MEDICAL SERVICES LLC DBA SYMBIUS MEDICAL LLC
BANNER PHYSICIAN SUPER SPECIALISTS ARIZONA LLC
PROGRESSIVE HEALTHCARE G
BANNER PRIMARY CARE PHYSICANS ARIZONA LLC
PROVIDERS DIRECT PLLC
BANNER SUN CITY MEDICAL GROUP
PULMONARY ASSOC OF SOUTH
BANNER THUNDERBIRD MEDICAL CENTER
RECOVERY HELP LLC
BANNER THUNDERBIRD SURGERY CENTER
REGIONAL CENTER FOR BORDER HEALTH
BANNER UMC PHX CAMPUS SURIGICAL SPEC
REHAB SOLUTIONS
BANNER UNIVERSITY MEDICAL CENTER
RITA RANCH DIALYSIS LLC
BANNER UNIVERSITY MEDICAL CENTER TUCSON
RNX INC WELLBEING INSTITUTE
BANNER UNIVERSITY MEDICAL CENTER PHOENIX CAMPUS
CRITICAL CARE
ROBERT BRIGGS
BANNER UNIVERSITY MEDICAL CENTER PHOENIX CAMPUS
FAMILY MEDICINE
SAGUARO FOUNDATION
BANNER UNIVERSITY MEDICAL CENTER PHOENIX CAMPUS
HOSPITALIST SERVICES
SAN PEDRO ANESTHESIA PLLC
BANNER UNIVERSITY MEDICAL CENTER PHOENIX CAMPUS
INTERNAL MEDICINE
SAN TAN FOOT AND ANKLE
BANNER UNIVERSITY MEDICAL CENTER PHOENIX CAMPUS
LIVER DISEASE SERVICES
SCOTTSDALE CENTER FOR AD
BANNER UNIVERSITY MEDICAL CENTER PHOENIX CAMPUS
MULTISPECIALTY SERVICES
SEABHS INC
BANNER UNIVERSITY MEDICAL CENTER PHOENIX CAMPUS
SURGICAL SERVICES
SIERRA VISTA GASTROENTEROLOGY PLLC
BANNER UNIVERSITY MEDICAL CENTER PHOENIX CAMPUS
TOXICOLOGY
SIERRA VISTA MEDICAL GRP
BANNER UNIVERSITY MEDICAL CENTER PHOENIX CAMPUS
WOMENS SERVICES
SIERRA VISTA REGIONAL HEALTH CENTER
BANNER UNIVERSITY MEDICAL GROUP
SIMPLY CLEAN AND GREEN LLC
BANNER UNIVERSITY MEDICINE CRISIS RESPONSE CENTER
SONORA BEHAVIORAL HEALTH HOSPITAL LLC
BANNER UNIVSERISTY MEDICAL CENTER PHOENIX CAMPUS
TRAUMA SERVICES
SONORA FAMILY CARE
BANNER URGENT CARE ARIZONA LLC
SONORA FAMILY CARE PLLC
BARRY E GERSHWEIR MD PC
SONORA QUEST LABORATORIES LLC
BARTON DIALYSIS LLC
BEACON GROUP
SONORAN FAMILY PRACTICE
SOUTHEASTERN AZ CONSUMER RUN SVCS DBA WELLNESS
CONNECTIONS
BENSON HOSPITAL
SOUTHERN ARIZONA INFECTIOUS DISEASE
BESCARE HOME LLC
SOUTHWEST BEHAVIORAL SERVICES INC
BILTMORE CARDIOLOGY
SOUTHWEST KIDNEY-DAVITA DIALYSIS PARTNERS LLC
BIO-REFERENCE LABORATORIES
SOUTHWESTERN CHILDRENS HEALTH SERVICE INC
BISBEE HOSPITAL ASSOCIATION
SOUTHWESTERN PALLIATIVE CARE ASSOCIATES
Health Passport Consent
Cenpatico Network Of Care
BREG
ST ELIZABETH HEALTH CENTER
BRIAN S PAGE DO PLLC
ST LOUIS MEDICAL SUPPLY
CANCER TREATMENT SERVICE
ST LUKES BEHAVIORAL HOSP
CANYONLANDS COMMUNITY HEALTHCARE CLINIC
ST LUKES MEDICAL CENTER
CARING CONNECTIONS FOR SPECIAL NEEDS LLC
STANLEY GERING
CARONDELET BEHAVIORAL HEALTH
SUN CITY DIALYSIS LLC
CARONDELET HOLY CROSS
SUN CITY WEST DIALYSIS
CARONDELET MEDICAL GROUP
SUN LIFE FAMILY HEALTH
CARONDELET SPECIALIST GR
SUN RADIOLOGY PC
CASA DE LOS NINOS INC
SUNSET COMMUNITY HEALTH
CASA DE TUCSON
SYLVAIN SIDI
CATHOLIC COMMUNITY SERVICE SOUTHERN AZ
TELECARE MENTAL HEALTH SERVICES OF ARIZONA INC
CEDARS HEART CLINIC
TENDER LOVING CARE HOME
CHILD & FMLY SUPPORT SVC
TERROS-MCDOWELL
CHILD AND FAMILY SERVICES OF YUMA INC
THE CHALE HOUSE LLC
CHIRICAHUA COMMUNITY HEALTH CENTERS INC
THE GUIDANCE CENTER
CHRISTIAN FAMILY CARE
THE HAVEN
COCHISE HEALTH AND WELLNESS
THE INSOMNIA & SLEEP INSTITUTE OF ARIZONA LLC
COCHISE LUNG CENTER PLLC
THE NEW FOUNDATION
COCHISE ONCOLOGY LLC
THE RESOLUTION GROUP INC
CODAC BEHAVIORAL HEALTH SERVICES OF PIMA COUNTY
THERANOS INC
COLORADO RIVER BEHAVIORAL HEALTH SYSTEM LLC
THOMAS A COURY
COLORADO RIVER BEHAVIORAL HEALTH SYSTEM LLC
TIDES CHANGE CTR WELLNES
COMMUNITY BRIDGES INC
TLC PEDIATRICS
COMMUNITY COUNSELING CENTERS INC
TMC ONE
COMMUNITY INTERVENTION ASSOCIATES INC
TOTAL MEDICAL CARE
COMMUNITY MEDICAL SERVICES
TOTAL RENAL CARE INC
COMMUNITY PARTNERSHIP CARE COORDINATION
TOTAL TRANSIT INC
COPE COMMUNITY SERVICES
TOUCHSTONE BEHAVIORAL HEALTH
CORAZON INC
TRANSITIONAL LIVING CENTER
CORNERSTONE HEALTH AND F
TRC FOUR CORNERS DIALYSIS CLINICS LLC
COUNSELING & CONSULTING
TUCSON CLINICA MEDICA FA
COYOTE TASK FORCE INC
TUCSON FAMILY CARE
CRISIS PREPARATION AND RECOVERY INC
TUCSON GASTROENTEROLOGY
CROSSROADS MISSION
TUCSON MEDICAL CENTER
DAVID GREENSPN MD PLLC
TUCSON PAIN INSTITUTE PC
DEAN D ETTINGER MD PC
UBH OF PHOENIX LLC DBA VALLEY HOSPTIAL
DESERT DOVE FARM INC
UHS OF PHOENIX LLC
DESERT KIDNEY ASSOCIATES
UHS OF TUCSON LLC
DESERT PAIN AND REHAB SPECIALISTS
UNITED CEREBRAL PALSY OF SOUTHERN ARIZONA
DESERT SENITA COMMUNITY HEALTH CENTER
UNITED COMMUNITY HEALTH CENTER
DEVEREUX AZ-SCOTTSDALE
UNIVERSITY OF ARIZONA
DIALYSIS CLINIC INC
VIBRANTCARE OUTPATIENT REHAB WEST INC
DIANE GENCO LPC
WEE CARE PEDIATRICS
Health Passport Consent
Cenpatico Network Of Care
DJO
WEST VALLEY INTERNAL MEDICINE
DK ADVOCATES INC
WHITE MOUNTAIN DERM LLC
DOMINION DIAGNOSTICS LLC
WICKENBURG HEALTHCARE ALLIANCE
DOUGLAS FAMILY CARE PLLC
WOMEN'S TRANSITION PROJ
DR BART J CARTER MD PC
YOUTH AND FAMILIES FIRST
DVA RENAL HEALTHCARE INC
YUMA GASTRO LLLP
DVA RENAL HEALTHCARE INC
YUMA REG MED CTR DBA YUMA REG CANCER CENTER LLC
EASTER SEALS BLAKE FOUNDATION
YUMA REGIONAL MED CTR
EDGEPARK
ZAREPHATH INC
EL RIO COMMUNITY HEALTH
EMPACT SUICIDE PREVENTION CENTER
ARIZONA DEPARTMENT OF CHILD SAFETY (DCS)
COMPREHENSIVE MEDICAL AND DENTAL PROGRAM (DCSCMDP)
FLORENCE CRITTENTON SVCS
DIVISION OF DEVELOPMENTAL DISABILITIES (AZDES-DDD)
FOCUS EMPLOYMENT SERVICES LLC
ARIZONA DEPARTMENT OF CORRECTIONS
FRANK LAUDONIO MD
ARIZONA DEPARTMENT OF JUVENILE CORRECTIONS
GILA VALLEY CLINIC PC
COCHISE COUNTY JAIL
GONZALES MEDICAL CLINIC
GRAHAM COUNTY JAIL
GORDON L GRADO MD INC
GREENLEE COUNTY JAIL
GRAND HOME DIALYSIS
LA PAZ COUNTY JAIL
GROSSMAN & GROSSMAN
PIMA COUNTY JAIL
HANGER PROSTHETICS ORTHOTICS WEST INC
PINAL COUNTY JAIL
HANGER PROSTHETICS ORTHOTICS WEST INC
SANTA CRUZ COUNTY JAIL
HAVASU REGIONAL MEDICAL CENTER
YUMA COUNTY JAIL
HAVEN BEHAVIORAL SERVICES OF PHOENIX LLC
CORRECT CARE SOLUTIONS (CCS)
HAVEN OF SAFFORD LLC
HEALTH NET ACCESS
HEALTHY LIFE FAMILY MEDICINE
HEALTH CHOICE AZ
HELPING ASSOCIATES INC
HEALTH CHOICE INTEGRATED
HELPING EVERYDAY YOUTH
UNITEDHEALTHCARE
HENRY L GIVRE MD FCCPPC
UNIVERSITY FAMILY CARE
HIGHER GROUND A RESOURCE CENTER
PHOENIX HEALTH PLAN
HOPE GROUP LLC
MERCY CARE PLAN
HOPE INC
MERCY MARICOPA INTEGRATED
HOPE LIVES VIVE LA ESPERANZA
CARE 1ST ARIZONA
HORIZON HEALTH AND WELLNESS INC
MARICOPA HEALTH PLAN
HOUSE CALL PT
CRS FULLY INTEGRATED
HOUSE OF HOPE
CRS PARTIAL ACUTE