Healthcare Annual Letter

Healthcare Annual Letter

Patient Name:    Date of Birth:

Patient Information

Emergency Contact

Insurance Information

Medical History — Annual Update

I certify that the following reflects my current medical information. If there are no changes from last year, check the box below.

No changes to medical history since last annual update.

Authorizations and Acknowledgments

By checking the boxes below, I grant the following consents necessary for my medical care and administration:

I authorize medical evaluation, treatment, and procedures as deemed necessary by authorized clinicians. I understand the nature, risks, and benefits of proposed routine treatments will be explained by my provider as appropriate.

I authorize release of my medical information to insurance payors and other health care entities for treatment, payment, and health care operations as required for administration and continuity of care.

I consent to voice, email, or text message communications regarding appointments, billing, and treatment reminders at the contact information listed above and understand that confidentiality cannot be guaranteed for unsecured communications.

I permit sharing of relevant clinical information with the following persons for care coordination:

I understand that I may revoke any of the above authorizations in writing at any time except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect disclosures made in reliance on this authorization prior to receipt of the revocation.

HIPAA & Privacy Practices Acknowledgment

I acknowledge that I have been offered or provided with the Notice of Privacy Practices that explains how my medical information may be used and disclosed and how I can obtain access to this information.

I acknowledge receipt of the Notice of Privacy Practices or decline to take a copy at this time.

Authorization Expiration

This authorization to use and disclose protected health information remains in effect until: . If no date is provided, this authorization will expire twelve months from the date of signature below.

Certification

I certify that the information provided in this annual update is true and correct to the best of my knowledge. I understand that knowingly providing false information may result in denial of benefits, termination of services, or other legal remedies permitted by law. I authorize the healthcare organization and its agents to verify information contained herein as necessary for my care and billing.

Sign Now