Healthcare Care of CA IV

HEALTHCARE CARE OF CA IV

Document Analysis

This document is a combined patient intake, consent for treatment, and authorization (Healthcare Care of CA IV). A real-world version contains (1) patient identification and contact information; (2) insurance and assignment of benefits; (3) medical history and current medications; (4) a clear description of the treatment/authorization being provided; (5) risks, benefits and alternatives; (6) HIPAA/privacy acknowledgement and authorization to release protected health information; (7) expiration and revocation provisions; and (8) patient certification and signature. Only the patient (or legally authorized representative) signs this form.

Patient Information

Date of birth:    Gender: Male Female Other Prefer not to say

Emergency Contact

Insurance Information

Subscriber date of birth:    I authorize assignment of insurance benefits to Healthcare Care of CA IV and accept financial responsibility for co-payments, deductibles, and non-covered services.

Medical History

Tobacco use: None Current Former    Alcohol use: None Social Regular

Consent for Treatment

I authorize Healthcare Care of CA IV, its licensed practitioners and staff, to provide such medical care and treatment as may be deemed necessary or advisable for diagnosis and treatment of my medical condition(s) including diagnostic tests, medications, injections and procedures. I understand the nature of the proposed treatment and that all medical care involves risks.

Risks and benefits: I acknowledge that risks, complications and side effects may occur with any treatment. I have had the opportunity to ask questions about expected benefits, material risks, likely alternatives and consequences if treatment is not rendered. I understand that no guarantees concerning results have been made to me.

By checking the box below I acknowledge that I have read and understand the above and consent to the proposed treatment.
I acknowledge and consent to the stated treatment and risks.

Authorization to Release / Obtain Medical Records

I authorize Healthcare Care of CA IV to release and/or obtain my protected health information (PHI) as necessary for treatment, payment, and healthcare operations or as I specifically direct below. This authorization includes records related to treatment, diagnosis, billing, mental health, and substance use treatment to the extent permitted by law unless I have specifically indicated limitations below.

I understand that I may revoke this authorization at any time in writing except to the extent that action has already been taken in reliance on this authorization. I understand that information disclosed pursuant to this authorization may be redisclosed by the recipient and may no longer be protected by federal privacy regulations.

HIPAA Privacy Acknowledgment

I acknowledge receipt of the facility's Notice of Privacy Practices describing how my health information may be used and disclosed and my rights with respect to my protected health information. I understand that I may request restrictions on certain uses or disclosures and that the facility will consider such requests in accordance with applicable law.

I acknowledge receipt of the Notice of Privacy Practices and understand my rights under HIPAA.

Financial Responsibility & Certification

I certify that the information provided on this form is true and accurate to the best of my knowledge. I accept responsibility for payments not covered by insurance, including co-payments, deductibles and non-covered services. I authorize release of medical information to process insurance claims and authorize payment of benefits to Healthcare Care of CA IV.

I understand that I may refuse any treatment and have the right to ask questions about the risks, benefits and alternatives to any proposed care. I attest that I am the patient or am legally authorized to sign on the patient's behalf and that I have the authority to execute this authorization.

Special Authorizations / Limitations

Acknowledgment and Signature

By signing below I acknowledge that I have read, understand, and agree to the terms of this intake, consent and authorization form. I understand that this authorization will remain in effect until the specified expiration date or until I revoke it in writing. I acknowledge that I have the right to receive a copy of this signed form.

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