Healthcare Annual Materials

HEALTHCARE ANNUAL MATERIALS

Patient Information

Patient Name:    Date of Birth:    Gender:

Insurance Information

Policy / ID Number:    Group Number:

Emergency Contact

Relationship:    Phone:

Medical History — Annual Update

I confirm that the following information reflects my current medical status. If any item has changed within the past year, provide details in the fields below and notify clinic staff promptly.

Tobacco use: Yes    Alcohol use: Yes    Recreational drug use: Yes

Authorizations and Consents

Consent to Treatment: I authorize clinicians and staff of this practice to provide medically necessary evaluation, diagnostic procedures, and treatment. I understand that no guarantees have been made to me as to the results of treatment. I retain the right to refuse or withdraw consent at any time by providing written notice to the practice.

Release of Medical Information: I authorize the release of my protected health information for the purposes of treatment, payment, and healthcare operations to other providers, payers, and business associates as required. This authorization includes release of records related to mental health, substance use disorder treatment, HIV/AIDS, and genetic testing where such disclosure is permitted by law.

HIPAA Acknowledgment: I acknowledge that I have been offered a copy of the Notice of Privacy Practices describing how my protected health information may be used and disclosed, and my rights under applicable privacy laws. I understand I may request restrictions on certain uses and disclosures; requests must be submitted in writing. I understand that the practice may deny requests that are not feasible or that conflict with applicable law.

Authorization for Electronic Communications and Messaging: I consent to receive appointment reminders, test results, billing statements, and other communications by the methods I select below. I understand that communications may not be fully secure and that I may revoke consent in writing.

Phone calls    SMS / Text messages    Email    Leave voicemail messages

Acknowledgments, Financial Responsibility, and Certifications

Accuracy Certification: I certify that the information provided on this form is true, complete, and accurate to the best of my knowledge. I agree to notify the practice promptly of any changes to insurance coverage, contact information, or medical status.

Financial Responsibility: I understand that I am financially responsible for services not covered or paid by my insurer, including co-payments, deductibles, and non-covered services. I authorize the release of information necessary to process claims and assign benefits to the provider, when applicable.

Photocopies and Electronic Copies: A photocopy or electronic copy of this signed authorization shall be valid and treated as an original.

Patient Affirmation

By signing below I confirm that I have read and understand the authorizations, acknowledgments, and consents contained in this Healthcare Annual Materials packet. I understand my rights to revoke authorizations in writing except to the extent that action has already been taken in reliance on the authorization.

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