Healthcare BBS Form

HEALTHCARE BBS FORM

Provider Information

Patient Information

Date of Birth:    Gender (check appropriate): Male Female Other / Prefer not to disclose

Emergency Contact

I consent to release limited information to the emergency contact named above in case of emergency.

Insurance / Billing Information

Medical & Behavioral Health History

History of substance use: Yes No

History of suicidal ideation or attempts: Yes No

Consent for Treatment

I, Patient Name: , authorize the Provider named above to provide behavioral health assessment, psychotherapy, counseling, medication management, and related services as clinically indicated. I understand that:

1. Risks and benefits: Therapy and medication have potential benefits and risks; no guarantee of specific outcomes.
2. Alternatives: I may decline or request alternative interventions at any time.
3. Voluntariness: Participation is voluntary and I may withdraw consent in writing, except where otherwise permitted by law.
4. Limits to confidentiality: Confidentiality does not apply to disclosures required by law, including imminent risk of harm to self or others, child or elder abuse, or court order.

I consent to treatment modalities discussed and authorize Provider to coordinate care with other treating clinicians for continuity of care. I understand I will be informed of material changes to the plan of care.

By checking this box I provide informed consent for the treatment described above.

HIPAA Privacy & Authorization to Use/Disclose Protected Health Information

I acknowledge that I have been offered a copy of the Provider's Notice of Privacy Practices describing how my health information may be used and disclosed. I understand my rights regarding my protected health information (PHI) and that the Provider has legal duties to protect PHI subject to federal and state law.

Authorization: I authorize the Provider to use and disclose my PHI for purposes of treatment, payment, and healthcare operations, including communication with insurance carriers and other healthcare professionals involved in my care, as set forth below.

Treatment and progress records
Billing and claims information
Psychotherapy notes (separate authorization required; check to confirm authorization)

I understand that I may revoke this Authorization in writing at any time except to the extent that action has already been taken in reliance on it. I understand that revocation must be submitted in writing to the Provider.

Telehealth & Electronic Communications

I consent to telehealth services when deemed appropriate by my Provider. I understand telehealth carries specific risks including electronic transmission failures and confidentiality limitations. I consent to secure electronic communications (email, portal messaging) as needed for scheduling, treatment summaries, and billing communications unless I indicate otherwise.

I consent to telehealth services and electronic communication.

Financial Responsibility & Assignment

I understand that I am financially responsible for services provided and for charges not covered by my insurance. I authorize the Provider to submit claims and assign benefits to the Provider for services rendered. I agree to promptly pay any patient-responsibility balances in accordance with Provider policies.

I authorize assignment of benefits to the Provider and consent to billing my insurance carrier.

Acknowledgment and Certification

By signing below I certify that the information I have provided is true and complete to the best of my knowledge. I have read, understand, and accept the terms of this document, including the limits of confidentiality, consent to treatment, HIPAA authorization, financial responsibility, and rights to revoke authorizations as described above.

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