Healthcare Adult Intake Packet

HEALTHCARE ADULT INTAKE PACKET

PATIENT INFORMATION

EMERGENCY CONTACT

INSURANCE INFORMATION

MEDICAL HISTORY

Please indicate whether you have a history of any of the following. Check all that apply. Checking a condition authorizes the clinician to review relevant history and pursue appropriate diagnostic steps.

SOCIAL HISTORY

REASON FOR VISIT / CURRENT SYMPTOMS

AUTHORIZATION AND CONSENT

Consent to Treatment: I authorize the clinicians and staff of this facility to provide medical care and services as deemed necessary and advisable. I understand that all medical care has risks and that the clinician has explained or will explain those risks, benefits, and reasonable alternatives upon request. I acknowledge the right to ask questions and to withdraw consent for non-emergency treatment at any time.

Assignment of Benefits and Financial Responsibility: I assign benefits to the provider for services rendered. I understand that I am financially responsible for any co-payments, co-insurance, deductibles, and any balance not covered by insurance. I agree that the provider may bill my insurance and release any necessary information to obtain payment.

Release of Information: I authorize the release of medical information necessary to process claims and to coordinate care with other providers. This authorization includes release of protected health information for treatment, payment, and healthcare operations, unless limited below.

HIPAA PRIVACY ACKNOWLEDGMENT

I acknowledge receiving the facility's Notice of Privacy Practices describing how my protected health information may be used and disclosed and how I can access this information. I understand that I may request restrictions on certain uses and disclosures and that I may revoke this authorization in writing except to the extent that action has already been taken in reliance on it.

MESSAGING AND CONTACT PREFERENCES

Consent to Contact: Please indicate how we may contact you regarding appointments, results, and billing.

ADDITIONAL AUTHORIZATIONS

PATIENT CERTIFICATION

By signing below I certify that the information I have provided on this form is true and accurate to the best of my knowledge. I authorize the use of telehealth or electronic communications when clinically appropriate. I understand that giving false information may jeopardize medical care and billing accuracy.

Sign Now