Healthcare Admit Paperwork

HEALTHCARE ADMIT PAPERWORK

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Other

Emergency Contact

Insurance Information

Medical History

Do you use tobacco products? Yes No

Are you pregnant or is there a possibility of pregnancy? Yes No

Reason for Visit / Presenting Complaint

Consent for Treatment and Authorization

I, the undersigned, consent to and authorize licensed physicians, nurses and other health care providers to perform diagnostic procedures and provide medical treatment deemed necessary for my care. I understand that all treatments, tests and procedures involve inherent risks, which may include but are not limited to infection, allergic reaction, unforeseen complications and death. The nature, risks and benefits of proposed treatments and alternatives have been explained to me in terms I can understand, and I have had an opportunity to ask questions.

I acknowledge that no guarantees have been made regarding the results of any examination or treatment. I understand I may withdraw this consent at any time, except to the extent that action has already been taken relying on this authorization.

I authorize the facility to obtain, review and disclose my medical information as necessary for treatment, payment and health care operations. This includes communication with other health care providers, insurers and their agents. I further authorize release of medical information to persons involved in my care and to designated emergency contacts unless otherwise restricted in writing.

HIPAA Privacy Acknowledgment

I acknowledge receipt of the facility's Notice of Privacy Practices. I understand that the Notice describes how my protected health information may be used and disclosed and how I may obtain access to this information. By signing below I hereby acknowledge that I have been provided an opportunity to review the Notice.

I authorize communication regarding appointments, billing and treatment reminders via the phone number and email provided, unless I have indicated otherwise in writing.

HIPAA Acknowledgment: I acknowledge receipt of the Notice of Privacy Practices.

Financial Responsibility and Assignment of Benefits

I understand that I am financially responsible for charges not covered by my insurance, including deductibles, copayments and non-covered services. I certify that the information provided regarding insurance coverage is accurate and complete. I authorize payment of benefits to the treating provider and assign benefits for the purpose of payment of medical services rendered.

Financial Responsibility Acknowledgment: I accept financial responsibility for charges not paid by my insurer.

Photograph / Media Consent

For clinical and identification purposes, photographs or video may be taken. I consent to such media being used for treatment, identification and internal quality assurance. I understand that media used for education or public purposes will require separate written authorization.

Media Consent: I consent to the use of photographs/video for clinical purposes.

Patient Rights and Acknowledgments

I have the right to receive considerate and respectful care, to be informed of my health status and recommended treatment, to refuse treatment to the extent permitted by law, and to be informed of potential risks and benefits. I understand how to submit complaints or grievances to the facility.

Acknowledgment and Certification

By signing below, I certify that the information I have provided on this form is true and correct to the best of my knowledge. I authorize the facility to proceed with medical evaluation and treatment as necessary. I understand that I may revoke any authorizations in writing, except to the extent that action has already been taken in reliance on such authorization.

Sign Now