Healthcare Acknowledgment Receipt

HEALTHCARE ACKNOWLEDGMENT RECEIPT

Facility/Provider Name:     Date of Service:

Patient Information

Insurance Information

Medical History Summary

Acknowledgments and Receipt

By signing below, I acknowledge and certify the following (initial and check as applicable):

I acknowledge receipt of the Facility's Notice of Privacy Practices and understand my rights regarding protected health information.

I acknowledge receipt of the Patient Rights and Responsibilities document and understand the rights described therein.

I acknowledge financial responsibility for services rendered and understand payment, billing, and collection policies as explained to me.

I acknowledge receipt of aftercare/home care instructions relevant to the services provided on the date above.

I consent to receive communications (including appointment reminders and billing statements) by telephone, text message, or email as appropriate.

Method of receipt: Paper: Electronic:

Authorization for Use and Disclosure

I authorize the Facility and my health care providers to use and disclose my protected health information as necessary for treatment, payment, and health care operations. I understand this authorization permits release of information required to process claims and coordinate care, including to insurance carriers and other health care entities.

I understand that this authorization remains in effect until: . I may revoke this authorization at any time by submitting a written revocation, except to the extent the Facility has acted in reliance upon this authorization.

Right to Withdraw & Certification

I understand my right to refuse to sign or to withdraw consent, and that withdrawing consent will affect only future uses and disclosures. I understand that services already provided will not be affected by a withdrawal to the extent the Facility relied on prior authorization.

Certification: I certify that the information provided on this form is accurate and complete to the best of my knowledge. I have had an opportunity to ask questions and have received answers to my satisfaction concerning the Notice of Privacy Practices, financial obligations, and the nature of the communications I may receive.

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