Healthcare Adult Packet

HEALTHCARE ADULT PACKET

Patient Information

Patient Name:

Male Female Other Prefer not to answer

Emergency Contact

Insurance Information

Medical History (check all that apply)

Diabetes Hypertension (high blood pressure) Heart disease Asthma / COPD History of cancer Bleeding disorder None of the above / other (specify below)

Current Medications

Allergies

Prior Surgeries / Hospitalizations

Consent for Treatment

I authorize staff of this practice to provide routine medical treatment and services as may be necessary in the judgment of the treating clinician. I understand that treatment may include diagnostic procedures, vaccinations, medications, and minor procedures. I acknowledge that no guarantees have been made to me as to the result of any treatment.

By signing this packet I consent to such treatment and understand I may refuse any specific procedure. I understand I have the right to ask questions, to be informed of risks and benefits, and to withdraw consent at any time prior to the provision of care.

I consent to the administration of standard emergency care if, in the judgment of clinicians, immediate treatment is required for my safety. I understand that, when feasible, the practice will attempt to contact my emergency contact prior to or immediately following emergency care.

Authorization to Release and Obtain Medical Records

I authorize the practice to release and obtain medical information, including diagnostic reports and treatment records, to and from other healthcare providers, hospitals, and insurers when necessary for my treatment, payment, or healthcare operations. This authorization includes records in electronic and paper form.

Assignment of Benefits and Financial Responsibility

I authorize the practice to bill my insurance and assign benefits directly to the practice for services rendered. I agree to be financially responsible for all charges not covered by my insurance, including copayments, coinsurance, deductibles, and non-covered services. I understand that I am responsible for notifying the practice of any changes to my insurance coverage.

HIPAA Privacy Acknowledgment

I acknowledge receipt of the practice's Notice of Privacy Practices which explains how my medical information may be used and disclosed and describes my rights regarding my protected health information. By signing below I acknowledge that I have been offered access to the Notice and understand my rights under applicable privacy laws.

I authorize the practice to communicate protected health information to the following individuals (name and relationship). If none, leave blank.

Communications and Telehealth

I consent to receive appointment reminders, treatment instructions, lab results, and billing communications via telephone, voicemail, text message, and email at the contact information provided. I understand that electronic communications may have privacy risks but that reasonable safeguards will be used.

I consent to telehealth visits where clinically appropriate. I understand that telehealth may have limitations and that I can request an in-person visit if desired.

Acknowledgment and Certification

I certify that the information I have provided on this packet is true, complete, and accurate to the best of my knowledge. I understand that knowingly providing false information may result in denial of benefits or termination of care.

By signing below I indicate that I have read and understand the above statements, that I have had an opportunity to ask questions, and that I consent to treatment, release of records, and financial responsibility as described in this packet.

Sign Now