Healthcare Annual Consents and Releases

Healthcare Annual Consents and Releases

Patient Identification

Patient Name:    Date of Birth:    Medical Record No.:

Insurance Information

Medical History (Relevant)

Consents and Authorizations

By signing below, I consent to and authorize the following as annual standing consents for the health care provider and their authorized agents:

General consent for treatment: I authorize clinicians to provide routine and emergency medical care, examinations, diagnostic tests, vaccinations, minor procedures, and related services as deemed necessary for my health while under care.

Authorization to release medical information: I authorize the release, disclosure and reproduction of my protected health information as necessary for treatment, payment, and healthcare operations or as specifically designated below.

Sensitive records: I specifically authorize release of sensitive information if applicable, including mental health, substance use treatment, HIV/AIDS related information, and genetic testing results, except as limited by state law or specified herein.

Authorization to communicate: I permit the provider to contact me regarding appointments, test results, and health information by the methods I specify below.

Phone call    Voicemail message    Text message    Email

Photographs and recordings: I authorize photographs, video, and audio recordings for clinical documentation, telehealth, treatment, or quality assurance purposes. Any non-clinical use will require separate written consent.

Assignment of benefits and financial responsibility: I assign insurance benefits to the provider for covered services and accept financial responsibility for charges not covered by my insurer, including deductibles, copayments, and non-covered services.

HIPAA / Privacy Acknowledgment

I acknowledge that I have been provided access to the provider's Notice of Privacy Practices describing how my protected health information may be used and disclosed and my rights with respect to that information. I understand that the provider may use or disclose my health information for treatment, payment, and healthcare operations as described in that notice.

I acknowledge receipt of the Notice of Privacy Practices.

Revocation, Duration and Certification

I understand that this authorization will remain in effect until the expiration date specified above or until revoked. I understand that I may revoke this authorization at any time by submitting a written revocation to the provider, except to the extent that action has already been taken in reliance on this authorization. I certify that the information I have provided on this form is accurate and complete to the best of my knowledge.

I understand that treatment cannot be conditioned on signing this authorization except where permitted by law. I further understand that information disclosed pursuant to this authorization may be subject to redisclosure and no longer protected by federal privacy regulations.

Additional Instructions / Limitations

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