Healthcare Admission Packet

HEALTHCARE ADMISSION PACKET

Patient Information

Date of Birth:    Gender: Male Female Other

Emergency Contact

Insurance Information

Subscriber Date of Birth:

Medical History

Please indicate if you have been diagnosed with any of the following (check all that apply):

Diabetes Hypertension Heart disease Asthma

Cancer Depression / Anxiety Kidney disease Other:

Consent to Treatment and Acknowledgments

By signing below I hereby authorize licensed providers and staff to perform diagnostic procedures and medical treatment as deemed necessary by the attending clinician. I understand that all medical procedures carry inherent risks and that no guarantee has been made as to results. I have been given an opportunity to ask questions and have had those questions answered to my satisfaction.

I understand that I have the right to refuse treatment or withdraw consent at any time, except where prohibited by law or where emergency treatment is required to prevent serious harm. I accept financial responsibility for services rendered that are not covered by my insurer and understand co-payments, deductibles, and non-covered charges are due as described by the facility's billing policies.

I consent to necessary medical treatment and procedures as described above.

HIPAA / Privacy Acknowledgment

I acknowledge that I have been provided an opportunity to review the facility's Notice of Privacy Practices describing how my protected health information may be used and disclosed. I authorize the release of medical information necessary for treatment, payment and healthcare operations consistent with applicable law.

I acknowledge receipt of the Notice of Privacy Practices and authorize disclosures as described above.

Release of Information & Assignment of Benefits

I authorize the facility to release medical and billing information to my insurer and its agents for purposes of payment and utilization review. I assign my insurance benefits to the facility and permit direct payment of benefits to the facility to the extent permitted by my policy. I understand I remain financially responsible for charges not paid by insurance.

Emergency Treatment Authorization

If I am unable to provide informed consent at the time treatment is required, I authorize the attending clinician to provide emergency medical care deemed necessary to preserve life or prevent serious deterioration of health. This authorization includes the use of reasonable force if necessary to effect treatment in an emergency.

I authorize emergency treatment as described above.

Advance Directives

Do you have an advance directive, living will, or durable power of attorney for healthcare? Yes No

Patient Certification

I certify that the information I have provided is accurate and complete to the best of my knowledge. I understand that providing false information may subject me to penalties and may affect my care. I authorize the facility and my providers to obtain, use, and disclose my protected health information as necessary to provide medical care and to process insurance claims, as set forth above.

I understand I may withdraw any authorization in writing, except to the extent that action has already been taken in reliance upon it. I give this consent voluntarily.

Sign Now