Healthcare Brochure

HEALTHCARE BROCHURE — PATIENT ACKNOWLEDGMENT

Facility Name:    Location/Department:

Patient Information

Date of Birth:    Gender:

Phone:    Email:

Relationship:    Phone:

Insurance Information

Policy / ID Number:    Group Number:

Medical History (Summary)

Brochure Content — Topics Provided

The following informational materials were provided to the patient. Please check all that apply:

Privacy Practices / HIPAA Notice

Patient Rights and Responsibilities

Billing, Insurance, and Collections Policy

Informed Consent for Treatments and Procedures (overview)

Advance Directives and Surrogate Decision-Making

Preventive Care and Screening Recommendations

Acknowledgment and Notices

By signing below I acknowledge that I received and had the opportunity to review the listed brochure materials. I understand these materials provide informational summaries about privacy practices, rights, billing, consent, and available services. These materials do not constitute individualized medical advice or replace conversations with a clinician.

I acknowledge that I may ask questions about any item in the brochures and may request further explanation or translation assistance. Receipt of brochures does not waive any statutory or regulatory privacy rights.

My decision to accept or decline any procedure, test, or treatment will be documented separately in an informed consent form when required. Refusing the brochure or any portion thereof will not affect my right to receive care.

Communication & Authorization Preferences

Preferred Method of Contact:    Phone    Text Message    Email    Mail

I authorize the facility to leave appointment reminders or limited health information by the selected contact methods:

I authorize release of the brochure topics acknowledgement to my listed emergency contact or legal representative for continuity of care:

Authorization Expiration Date (if applicable):

Language & Accessibility

Primary Language Spoken:    Interpreter Needed:

Patient Questions / Comments

Acknowledgment of Receipt

I certify that the information I have provided on this form is true and accurate to the best of my knowledge. I acknowledge receipt of the above-listed brochure materials and understand the facility's statements regarding their informational purpose and my rights.

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