Healthcare Care Renewal Form

Healthcare Care Renewal Form

Patient Information

Patient Name:

Date of Birth:   Gender:

Emergency Contact

Insurance Information

Medical History and Current Status

Current Medications (name, dose, frequency):

Allergies (medication, food, environmental):

Recent hospitalizations, emergency visits, or surgeries since last plan:

Functional Status & Care Needs

Mobility:   Cognition:

Activities of Daily Living assistance required (check all that apply):

Bathing    Dressing    Ambulation    Toileting    Feeding    None

Services to be Renewed

Select services requested for renewal and indicate frequency:

Skilled Nursing    Physical Therapy    Occupational Therapy    Speech Therapy

Home Health Aide    Medication Assistance    Wound Care    Infusion Therapy

Authorization and Consent to Renew

I authorize the renewal of the identified services for the patient named above. I understand that this renewal authorizes the provider and its clinical staff to provide, coordinate, and bill for the services described in this form for the renewal period identified below. I acknowledge that services will be provided pursuant to the patient's established plan of care and applicable professional standards.

Renewal Period Start Date:   Renewal Period End Date:

I understand that I have the right to revoke this authorization at any time by providing a written revocation to the provider. Revocation will not affect any uses or disclosures made in reliance on this authorization prior to receipt of the revocation. I understand that unless revoked earlier, this authorization will expire on the Authorization Expiration Date indicated above.

Privacy, Information Exchange, and Billing

I authorize the release and exchange of clinical information necessary to arrange, provide, and coordinate care for the purposes of treatment, payment, and healthcare operations. This may include the release of relevant medical records, medication lists, and discharge summaries to other treating providers, payers, and care coordination entities. I acknowledge that information disclosed pursuant to this authorization may include sensitive health information as permitted by law.

Financial Responsibility: I authorize the provider to bill my insurance and accept payment directly from my insurer. I understand I remain responsible for any co-payments, deductibles, or services not covered by insurance. I agree to notify the provider of any changes in insurance coverage.

Acknowledgment of Privacy Practices: I acknowledge that I have been offered or provided a copy of the provider's Notice of Privacy Practices.

Emergency Treatment Authorization: I authorize emergency treatment if required while receiving services under this renewal.

Attestation

By signing below I certify under penalty of perjury that the information provided on this Healthcare Care Renewal Form is true, accurate, and complete to the best of my knowledge. I consent to the renewal of services as indicated and affirm that I have had the opportunity to ask questions regarding the renewed care plan and associated risks and benefits.

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