Healthcare Admissions Packet

HEALTHCARE ADMISSIONS PACKET

Admission Details

Admission Date:    Admission Type: Inpatient Outpatient Emergency

Patient Information

Male Female Other Prefer not to say

Emergency Contact

Insurance Information

Medical History

Please indicate current or past medical conditions (check all that apply):

Diabetes Hypertension Heart disease Asthma/COPD

Depression/Anxiety Kidney disease None of the above

Tobacco use: Current Former Never

Consent for Treatment and Financial Agreement

I, the undersigned, authorize physicians and staff to provide medical care as deemed necessary and appropriate for my diagnosis and treatment. I acknowledge that no guarantee or assurance has been made as to the results of treatments or procedures. I consent to routine diagnostic procedures, laboratory testing, imaging, medications, and treatment necessary for my care.

I accept financial responsibility for services rendered and agree to pay charges not covered by my insurance, including deductibles, co-payments, and non-covered services. I authorize assignment of medical benefits to the provider and permit release of medical information to my insurance carrier when necessary for claims processing.

HIPAA Privacy & Release of Information

I acknowledge receipt of the facility's Notice of Privacy Practices which describes how my health information may be used and disclosed. I understand that I may request restrictions on certain uses and disclosures and that I have rights to inspect and obtain a copy of my medical records as provided by law.

I authorize the release of medical information necessary to process claims and coordinate care with other healthcare providers, insurers, and authorized individuals. This authorization includes release of information related to mental health, communicable diseases, and substance use disorder treatment where permitted by law.

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

Authorization to Release Medical Records

I authorize the facility to release copies of my medical records to the following individual(s) or entity(ies) for purposes of continuity of care and claims processing. I understand this authorization may be revoked in writing at any time except to the extent that action has already been taken in reliance on it.

Advance Directives & Special Instructions

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

Patient Rights and Acknowledgments

I understand that I have the right to receive information about my diagnosis, treatment options, estimated costs, and potential risks and benefits of proposed treatments. I have had the opportunity to ask questions and understand the information provided. I understand I may withdraw consent at any time by notifying my treating provider, subject to clinical considerations.

By signing below, I certify that the information provided in this admissions packet is true and correct to the best of my knowledge and that I have the authority to execute this document. I authorize the facility and its agents to act in accordance with the consents and authorizations contained herein.

Sign Now