Healthcare Background Info Form

HEALTHCARE BACKGROUND INFO FORM

Patient Information

Patient Name:

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History

Primary Care Provider:

Diabetes    Hypertension    Heart disease    Asthma    Cancer

Kidney disease    Liver disease    Thyroid disease    Other:

Lifestyle and Social History

Tobacco Use: Never   Current   Former

Alcohol Use: None   Social   Regular

Current Complaint / Reason for Visit

Authorization, Consent, and Privacy

Consent for Treatment: I authorize the provision of routine medical care, diagnostic procedures, and emergency treatment as deemed necessary by the treating clinicians. I understand that no guarantee has been made regarding the results of examination or treatment.

Financial Responsibility and Release: I accept financial responsibility for services provided and authorize the release of medical information necessary for treatment, payment, and healthcare operations. I authorize payment of insurance benefits to the provider for services rendered.

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

I authorize the release of my medical records to:

Purpose of Release:

HIPAA Acknowledgment

Notice of Privacy Practices: I acknowledge that I have been provided with or offered a copy of the provider's Notice of Privacy Practices describing how my health information may be used and disclosed. I understand that more detailed information is available upon request and that I may direct questions or complaints to the provider's privacy official.

Authorization for Electronic Communication: I consent to receive appointment reminders, billing communications, and other health-related communications via phone, text, or email unless I decline such communications in writing.

Certification

By signing below I certify that the information provided on this form is true and complete to the best of my knowledge. I understand that intentionally providing false information may result in the denial of services or other action by the provider. I consent to treatment and the uses and disclosures described above.

If signing on behalf of the patient, indicate relationship and authority to sign:

I am signing as legal guardian / authorized representative    Relationship:

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