Healthcare Application Packet

HEALTHCARE APPLICATION PACKET

Patient Information

Patient Name:

Female Male Non-binary/Other Prefer not to say

Emergency Contact

Insurance Information

Medical History

Please indicate any of the following conditions previously diagnosed (check all that apply):

Diabetes Hypertension Heart disease Asthma/COPD

Renal disease Liver disease Mental health condition None of the above

Consent for Treatment

I authorize the medical staff of this facility to provide evaluation, diagnostic procedures, and medical treatment as may be necessary for my care. I understand that no guarantees have been made to me regarding the results of treatment. I have the right to request information about the nature and purpose of proposed procedures and reasonable alternatives.

By checking the box below I acknowledge that I have read and understand this consent and authorize treatment:

I consent to necessary evaluation and treatment

Authorization for Use and Disclosure of Protected Health Information (PHI)

I authorize the release of my protected health information as described below. I understand that this authorization is voluntary and that I may revoke it in writing at any time except to the extent that action has already been taken in reliance on it.

I understand that information used or disclosed pursuant to this authorization may include information relating to behavioral health, communicable diseases, HIV status, and genetic testing unless I specifically mark the following categories to be excluded:

Exclude behavioral/mental health records Exclude HIV-related information

Financial Responsibility and Assignment of Benefits

I accept financial responsibility for services rendered that are not paid by my insurer, including copayments, deductibles, and services not covered. I authorize payment of medical benefits to the provider for services rendered and authorize release of information necessary to process claims.

I acknowledge financial responsibility and authorize assignment of benefits

Acknowledgement of Privacy Practices

I acknowledge that I have been offered or received a copy of the provider's Notice of Privacy Practices describing how my health information may be used and disclosed and explaining my rights regarding that information.

I acknowledge receipt of privacy practices

Certification

By signing below I certify that the information provided on this Healthcare Application Packet is true and complete to the best of my knowledge. I understand that falsification or omission of material information may be grounds for denial of services and may subject me to legal penalties.

Certification: I declare under penalty of perjury that I am the patient or am authorized to sign on behalf of the patient and that the information provided herein is accurate. I understand that this document authorizes release of medical information as specified and that I may revoke this authorization in writing, except to the extent that action has been taken in reliance on it.

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