Healthcare Care of TX Form

CARE OF TX - PATIENT INTAKE & AUTHORIZATION

Patient Name:    Date of Birth:    Medical Record/Account No.:

Patient Information

Male   Female   Other/Non-binary   Prefer not to disclose

Emergency Contact

Insurance Information

Medical History

Consent for Treatment

I hereby authorize Care of TX and its licensed providers and personnel to perform such diagnostic, therapeutic and supportive procedures as may be necessary in the judgment of the treating provider. This authorization includes examinations, tests, routine procedures and the administration of medications and vaccines when clinically indicated.

I understand the nature of the proposed treatment and that risks and complications may include, but are not limited to, infection, allergic reaction, bleeding, pain, scarring, and other risks specific to the procedure described above. Benefits and alternatives have been explained to me in terms I can understand. I acknowledge that no guarantees regarding outcome have been made.

I understand that I may withdraw this consent at any time prior to the performance of any procedure by providing written notice to Care of TX. Withdrawal of consent will not affect treatment already provided or obligations for payment for services rendered.

By initialing below I acknowledge that I have had the opportunity to ask questions regarding the proposed care and that such questions have been answered to my satisfaction:

Initials:

Authorization for Release of Medical Information

I authorize Care of TX to release medical information from the patient record as follows for the purpose indicated. I understand that information released pursuant to this authorization may include records related to mental health, substance use disorder treatment, and sexually transmitted infections unless I specifically indicate exclusions below.

Complete medical record   Billing and payment records   Immunization records   Laboratory/test results

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. This authorization will expire on the date specified above or, if no date is specified, twelve months from the date of my signature.

Financial Responsibility & Assignment of Benefits

I agree to be financially responsible for all charges for services provided to me or my dependent. I authorize and assign insurance benefits to be paid directly to Care of TX for services rendered. I understand that I am responsible for any co-payments, deductibles, non-covered services, and charges not paid by my insurer.

If applicable, I permit release of information necessary to process insurance claims and certify that the information provided on this form is true and complete to the best of my knowledge.

HIPAA Acknowledgment

I acknowledge that I have been offered or given the organization’s Notice of Privacy Practices describing how medical information about me may be used and disclosed. I understand that I may request restrictions on certain uses and disclosures and that such requests must be made in writing.

I acknowledge receipt of the Notice of Privacy Practices: Received   Declined

Acknowledgment and Certification

By signing below I certify that I am the patient or authorized representative of the patient and that the information I have provided on this form is true and correct. I understand that falsification of information may result in denial of coverage or other administrative action. I authorize the release of medical information as set forth above and consent to the provision of treatment.

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