Create Provider List

This tells the Foundation who to contact on your behalf. Be sure to include the clinic or hospital (not the doctor’s) name as well as the city and state.

Patient’s Providers

I authorize said healthcare providers listed below to disclose records obtained in the course of my evaluation and/or treatment to be delivered to the below party preferably by FHIR interface so that updates can be made with a minimum of human interaction.  If this method is unavailable Electronic facsimile and/or email is preferred.  In the case where the only option is via paper please send by USPS or delivery service

CriticalConneciton Health Foundation
8400 North MoPac Expressway
Suite 200
Austin, TX 78759
Phone(512) 236-1887
email: PatientForms@CriticalConnection.com
Fax: 877-479-4066

 

I have read the above, or have had it read to me, and authorize the disclosure of my Protected Health Information as stated.