Healthcare Admit Document

HEALTHCARE ADMIT DOCUMENT

Patient Information

Date of Birth:    Gender: Male Female Other

Emergency Contact

Insurance Information

Subscriber Date of Birth:

Medical History

Admission & Procedure Information

Attending Physician:    Admission Date:

Consents, Authorizations and Acknowledgements

Consent to Treatment: I, the undersigned, authorize physicians, nurses and staff of this facility to perform and administer such diagnostic, therapeutic and medical procedures as are considered necessary for diagnosis and treatment. I have had an opportunity to ask questions regarding the nature, risks, benefits and alternatives of the proposed treatment or procedure and understand that no guarantees have been made to me concerning the results of treatments.

Risks and Benefits: I acknowledge that risks and potential complications, including but not limited to infection, bleeding, allergic reaction, adverse reaction to medications or anesthesia, and other potential risks have been explained to me in language I understand. I accept the benefits and risks described and consent to the recommended care.

Right to Withdraw: I understand that I may withdraw consent for non-emergency treatment at any time prior to the commencement of that treatment by notifying the attending provider, except in circumstances where immediate treatment is required to prevent serious harm.

Authorization to Release Medical Information: I authorize the facility to release my medical information to my insurance carriers and to other healthcare providers for treatment, payment and healthcare operations. I understand that a separate authorization is required for release of psychotherapy notes and certain sensitive information unless otherwise permitted by law.

Assignment of Benefits and Financial Responsibility: I assign benefits payable under my insurance to the facility and authorize payment directly to the facility. I understand that I am financially responsible for all charges not covered by insurance, including deductibles, co-payments and non-covered services. If services are provided by an independent practitioner, I understand I may receive separate bills.

Advance Directives / Power of Attorney: I have been asked whether I have an advance directive or health care power of attorney and have been given the opportunity to provide documentation. If I am unable to make decisions, I direct that the person designated below act on my behalf:

HIPAA Privacy Acknowledgement

I acknowledge receipt of the facility's Notice of Privacy Practices describing how my protected health information may be used and disclosed, and my rights with respect to that information under applicable law. I understand I may request restrictions on certain uses and disclosures, and that requests will be considered in accordance with law and facility policy.

Authorization for Release / Expiration

This authorization will expire on:

Acknowledgement and Certification

By signing below, I certify that the information provided on this admit document is true and accurate to the best of my knowledge. I understand the policies described above and acknowledge my financial responsibility for services not covered by third-party payers. I authorize treatment as described and authorize payment of benefits to the facility when applicable.

I understand that I may revoke authorizations provided herein at any time in writing, except to the extent that action has already been taken in reliance upon such authorizations. Revocation does not affect disclosures made prior to receipt of the revocation.

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