Healthcare Annual Signatures

Healthcare Annual Signatures

This Healthcare Annual Signatures form documents the patient’s current contact, insurance and medical information, and records annual acknowledgments and authorizations required for treatment, billing, release of information, and privacy practices. By signing below the patient (or legal representative) certifies the accuracy of the information provided, grants the authorizations selected, and acknowledges the rights and notices stated herein.

Patient Information

Date of Birth:

Male    Female    Other    Decline to State

Emergency Contact

Insurance Information

Subscriber Date of Birth:

Medical History (update)

Annual Authorizations and Acknowledgments

The patient acknowledges and provides the following authorizations by selecting each applicable box and initialing. Each checked authorization constitutes a separate, specific written authorization under applicable privacy and medical billing laws.

I consent to routine medical evaluation, diagnostic testing, and treatment as deemed necessary by the clinicians of this practice. I understand that the nature, benefits, risks and alternatives to proposed treatments will be explained when applicable.    Initials:

I authorize release of my protected health information to insurers, third-party payers, or other providers as necessary for treatment, payment, and health care operations. This authorization includes the release of clinical summaries, billing information, and insurance correspondence as required for claims adjudication.    Expiration (if different from record retention policy):

I acknowledge receipt of the Notice of Privacy Practices and understand how my health information may be used and disclosed. I understand I may request restrictions and receive an accounting of disclosures as allowed by law.    Initials:

I authorize the practice to contact me by telephone at the numbers provided for appointment reminders, clinical communications, and billing matters.    I authorize text message communications.    I authorize email communications.    Initials:

I assign medical benefits to the provider and authorize payment of benefits directly to the practice. I understand I am financially responsible for charges not covered by insurance, including co-payments, deductibles, and non-covered services.    Initials:

I consent to receiving telehealth services when offered, including videoconferencing and telephone encounters. I understand telehealth has limitations and privacy risks, and I may decline telehealth and request an in-person visit when available.    Initials:

I authorize or decline photography/video for clinical documentation and treatment planning. I understand separate consent will be requested for use of images for promotional or research purposes.    Allow    Decline

Right to Revoke / Duration

Except where action has already been taken in reliance on an authorization, the patient or authorized representative may revoke any authorization in writing at any time. Revocation does not affect disclosures already made in reliance on a valid authorization. Unless otherwise specified above, authorizations provided on this form remain in effect for the duration necessary for treatment, billing, and health care operations or until revoked in writing.

I understand that refusal to sign or later revocation of certain authorizations may result in limited ability for the provider to obtain insurance payment or to coordinate care with other providers.    Initials:

Certification

By signing below I certify that the information on this form is true and complete to the best of my knowledge. I authorize the release of medical information necessary to process claims and to facilitate my care. I accept financial responsibility for services rendered that are not paid by third-party payers. I understand that electronic and paper copies of this document are equally valid.

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