Healthcare Agreement Package

Healthcare Agreement Package

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Other/Prefer not to state

Insurance Information

Medical History

Consent for Treatment

Description of Proposed Treatment or Services:

I authorize the clinical staff to provide routine diagnostic and therapeutic services related to the treatment described above. I acknowledge that no guarantee has been made as to the results of any treatment. I understand the reasonably foreseeable risks, complications, and alternatives associated with the proposed treatment, including but not limited to infection, bleeding, allergic reaction, and unanticipated outcomes. I have had the opportunity to ask questions and have received answers to my satisfaction.

I understand that I may withdraw this consent at any time prior to a procedure or treatment by notifying the treating clinician in writing, except to the extent that action has already been taken in reliance on this consent.

I consent to the proposed treatment and related clinical care as described above.

Authorization to Release Medical Records

I authorize the release of my protected health information to:

Purpose of Disclosure:

This authorization shall remain in effect until unless earlier revoked in writing. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations.

HIPAA Privacy Acknowledgment

I acknowledge that I have been offered or received a copy of the provider's Notice of Privacy Practices describing how my health information may be used and disclosed and my rights with respect to that information.

I acknowledge receipt of the Notice of Privacy Practices or decline to acknowledge receipt.

Financial Responsibility and Assignment of Benefits

By signing below, I accept financial responsibility for services rendered and agree to pay all charges not covered by insurance, including co-payments, deductibles, and non-covered services. I authorize and assign benefits payable from my insurer to the treating provider to the extent permitted by law. I further agree to be responsible for reasonable collection and legal costs incurred to collect overdue balances.

I authorize assignment of insurance benefits to the provider and certify that the information provided on this form is true and complete to the best of my knowledge.

Additional Authorizations & Notices

If the patient is a minor or otherwise unable to consent, the undersigned certifies that he/she is the parent, legal guardian, or person authorized to consent on behalf of the patient and has the legal right to execute this Agreement. Execution of this document constitutes an admission that the signer has the authority to execute on behalf of the patient where applicable.

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