Healthcare Admission Document

HEALTHCARE ADMISSION DOCUMENT

Facility Name:   Admission Date:

Patient Information

Date of Birth:   Gender:   Marital Status:

Phone:   Alternate Phone:   Email:

Emergency Contact

Relationship:   Phone:

Insurance Information

Policy Number:   Group Number:

Subscriber DOB:   Policy Holder Relationship:

Medical History

Primary Care Physician:   Height/Weight:

Reason for Admission / Proposed Treatment

Admitting Physician:   Attending Service/Unit:

Consent for Treatment and Admission

I, the undersigned patient (or guardian), hereby consent to admission to the facility named above and authorize the physicians, nurses and other healthcare professionals to provide such medical care, diagnostic tests, surgical procedures, anesthetic, medications and other treatments as are deemed necessary for my care. This authorization includes routine diagnostic and therapeutic procedures, administration of medications, and any ancillary services reasonably necessary for diagnosis and treatment.

I acknowledge that risks and complications associated with proposed treatments and procedures have been explained to me in terms I understand. I understand that no guarantee has been made as to the results of treatment. I retain the right to ask questions and to refuse or withdraw consent at any time prior to receiving sedation, anesthesia, or a procedure, subject to medical recommendations concerning emergent care.

In certain circumstances, blood transfusion may be medically necessary. I consent to receive blood products if clinically indicated: Consent to blood products    Decline blood products

I consent to the administration of anesthesia if required for the procedure(s), including local, regional and general anesthesia, with understanding of attendant risks. If I decline anesthesia, I acknowledge that certain procedures may not be performed. Consent to anesthesia    Decline anesthesia

Financial Responsibility and Assignment

I certify that the insurance information provided is true and accurate to the best of my knowledge. I authorize the release of medical information necessary to process claims and request payment of benefits be made to the facility and its providers. I understand that I am financially responsible for charges not paid by my insurer, including deductibles, co-payments, co-insurance, and non-covered services. I agree to pay all collection costs and reasonable attorney fees if my account is placed in collection.

If payment is the responsibility of a third party or guarantor, I will provide accurate guarantor information below.

HIPAA Privacy Acknowledgment and Authorization

I acknowledge that I have been offered the facility's Notice of Privacy Practices. I understand that my protected health information may be used and disclosed for treatment, payment and health care operations as described in the Notice. I authorize disclosure of my protected health information to the following persons (name and relationship) for purposes of care coordination and billing:

This authorization for release of protected health information will expire on: . I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it.

Additional Information / Special Instructions

Patient Certification

I certify that the information provided on this admission form is complete and accurate to the best of my knowledge. I understand that providing false or misleading information may affect my care or financial responsibility. I have had the opportunity to ask questions regarding my treatment, risks, alternatives and financial obligations and those questions have been answered to my satisfaction.

If signed by a legal guardian or authorized representative, provide relationship and authority:

Sign Now