Healthcare Admit Pack

HEALTHCARE ADMIT PACK

Facility and Admission

Facility Name:

Admission Date:    Admitting Provider:

Patient Information

Date of Birth:    Gender: Male Female Other Prefer not to say

Primary Phone:    Email:

Emergency Contact

Relationship:    Contact Phone:

Insurance Information

Policy Number:    Group Number:

Subscriber Date of Birth:    Secondary Insurance:

Medical History

Do you use tobacco? Yes No    Do you consume alcohol? Yes No    Pregnant or possibly pregnant? Yes No

Consent for Treatment

I hereby authorize healthcare providers and staff of the Facility to provide medical evaluation and treatment as deemed necessary by the treating clinicians. This authorization includes routine diagnostic procedures, administration of medications, anesthesia, and minor or major surgical procedures when necessary. I understand that all interventions carry potential risks including infection, bleeding, allergic reaction, complications of anesthesia, and other risks inherent to medical care which cannot be fully enumerated here.

I understand that I may refuse or withdraw consent at any time prior to the procedure or treatment, and that withdrawing consent may have medical consequences. I acknowledge that the treating clinicians have explained the nature and purpose of the proposed care, as well as reasonable alternatives and the risks and benefits.

Consent to blood transfusion if required: Yes No

I confirm that I have had the opportunity to ask questions and that my questions have been answered to my satisfaction: Initials:

HIPAA Authorization and Privacy Acknowledgment

I authorize the release of my protected health information to the individuals or entities identified below for purposes of treatment, payment, and healthcare operations. I understand that this authorization is voluntary, and that I may revoke this authorization in writing except to the extent that action has already been taken.

This authorization expires on:

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

Financial Responsibility

I understand that I am financially responsible for services provided by the Facility that are not covered or paid by my insurance. I authorize payment of insurance benefits to the Provider for services rendered and authorize the release of medical information necessary to process claims. I agree to pay any copayments, deductibles, or balances not paid by my insurer in accordance with Facility policy.

If I am signing on behalf of the patient, I certify that I am authorized to consent to treatment and accept financial responsibility on behalf of the patient.

Advance Directives and Patient Rights

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

Acknowledgment of Accuracy

I certify that the information provided in this Admit Pack is true and complete to the best of my knowledge. I will notify the Facility of any changes to my health status, contact information, or insurance coverage.

Patient Initials:

Sign Now