Healthcare Care of OH II

Healthcare Care of OH II

This form documents patient registration, clinical authorization, HIPAA authorization, and release for Healthcare Care of OH II. Completion of this form authorizes Healthcare Care of OH II and its licensed staff to provide routine and urgent medical care, to bill insurance as authorized below, and to disclose protected health information as specified in the HIPAA Authorization and Release sections. Patient information provided below is accurate to the best of the signer’s knowledge.

Patient Information

Date of Birth:   Phone:   Email:

Female    Male    Non-binary    Prefer not to say    Other:

Emergency Contact

Relationship:   Phone:

Insurance Information

Policy Number:   Group Number:

Subscriber Date of Birth:    Authorization to bill insurance for services:

Medical History

Primary Care Physician:   Phone:

Do you have an advance directive or durable power of attorney for health care? Yes    No    If yes, location of document:

Consent for Treatment

I hereby authorize Healthcare Care of OH II and its licensed practitioners, nursing staff, technicians and other authorized personnel to provide medical care, diagnostic testing, therapeutic procedures, and medication administration that, in the judgment of such personnel, are necessary or advisable for my condition. This authorization includes routine examinations, laboratory testing, radiology, immunizations, wound care, and other outpatient services. Procedures that are non-routine or carry significant risk will be explained in writing and additional consent will be requested when required by law.

Description of anticipated care or procedure(s):

Risks and benefits: I understand that all medical procedures carry risks, including but not limited to allergic reactions, infection, bleeding, or unforeseen complications. Benefits may include diagnosis, relief of symptoms, and improved health outcomes. I have the right to ask questions and to refuse any treatment or procedure except as limited by applicable law.

Right to withdraw: I understand I may withdraw my consent to future treatment at any time by providing written notice to Healthcare Care of OH II. Withdrawal of consent will not affect care already provided in reliance on this authorization.

HIPAA Authorization and Privacy Acknowledgment

I acknowledge receipt of the Notice of Privacy Practices and understand my rights regarding protected health information. I authorize Healthcare Care of OH II to use and disclose my protected health information for treatment, payment and healthcare operations consistent with the Notice of Privacy Practices and applicable law.

Persons or entities authorized to receive my health information (name and relationship):

Acknowledgement of HIPAA notice: I acknowledge that I have received and reviewed the Privacy Notice.

Authorization expiration date (if different from default six (6) months):

Authorization for Release of Medical Information

I authorize the release of my medical records and health information to the persons or organizations listed below for the purposes indicated. I understand that information disclosed pursuant to this authorization may include mental health records, substance abuse treatment records, HIV/AIDS-related information, and other sensitive information if such information is relevant and specifically identified below.

Purpose of disclosure: Continuity of care    Insurance claim/benefits    Legal    Other:

I understand that I may revoke this authorization at any time by submitting written notice to Healthcare Care of OH II, except to the extent that action has been taken in reliance on this authorization. Unless revoked earlier, this authorization will expire as indicated above or in six (6) months from the date of my signature.

Patient Certifications

By signing below I certify that: (1) I am the patient or authorized representative of the patient; (2) the information supplied in this form is accurate to the best of my knowledge; (3) I authorize the release of medical information as described above; (4) I authorize Healthcare Care of OH II to furnish and bill insurance for services as indicated; and (5) I have had an opportunity to ask questions about the information on this form and the proposed treatment.

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