Healthcare Ancillary Packet

HEALTHCARE ANCILLARY PACKET

Patient Information

Date of Birth:    Gender:

Phone:    Email:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy / ID Number:    Group Number:

Medical History

Ancillary Services Requested

Please indicate requested ancillary services (check all that apply):

Laboratory testing (blood work, cultures)
Diagnostic imaging (X-ray, CT, MRI, ultrasound)
Physical / Occupational Therapy
Durable Medical Equipment (DME)
Telehealth consultation
Other (specify):

Consent for Ancillary Services

Provider Name:    Service/Procedure:

Intended Date of Service:

I hereby authorize the above-named provider and the provider's agents and staff to perform the ancillary services described above. I have been informed of the nature and purpose of the proposed services, the expected benefits, and the reasonably foreseeable risks and complications. I understand that results cannot be guaranteed and that alternative treatment options have been explained when applicable.

I understand my right to ask questions and to have those questions answered prior to the commencement of services. I acknowledge that I may withdraw this consent at any time by providing written notice, except when services have already been performed or when withdrawal would jeopardize my health or safety.

Authorization to Release Records & Assignment of Benefits

I authorize the release of medical information necessary to process claims related to the ancillary services requested herein. This authorization includes records related to diagnosis, treatment, billing, and payment. I understand that a copy of this authorization is valid and has the same force as the original.

Assignment of Benefits: I assign to the provider any insurance benefits otherwise payable to me for services rendered. I understand that I remain financially responsible for charges not covered or payable by insurance. This assignment will remain in effect until revoked in writing.

Release records to insurer for claim processing:     Release records to family or designated individual:

HIPAA Authorization & Privacy Acknowledgment

I acknowledge receipt of the provider's Notice of Privacy Practices and understand how my protected health information may be used and disclosed for treatment, payment, and healthcare operations. I authorize the use and disclosure of my protected health information as reasonably necessary to accomplish the purposes described above.

Patient acknowledges privacy practices:

Financial Responsibility & Billing

I understand that I am financially responsible for all charges for services rendered by the provider that are not paid by insurance or other third-party payers. I agree to pay any co-payments, deductibles, coinsurance, and amounts deemed patient responsibility by my insurer. If my account is referred for collection, I agree to pay reasonable collection costs and attorney fees to the extent allowed by law.

Patient accepts financial responsibility:

Authorization Duration and Revocation

This authorization will expire on: unless earlier revoked in writing. Revocation must be submitted in writing to the provider and will not affect disclosures made prior to the provider's receipt of the revocation.

Patient Certification

By signing below I certify that the information provided in this Ancillary Packet is true and complete to the best of my knowledge. I authorize the described ancillary services, the release of information as indicated, and the assignment of benefits as stated. I understand that I may request a copy of this signed authorization for my records.

If signed by a legal guardian or personal representative, indicate relationship and authority to sign:

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