Healthcare Care Signature Pages

HEALTHCARE CARE SIGNATURE PAGES

Patient Information

Patient Name:     Date of Birth:

Male   Female   Other   Prefer not to disclose

Emergency Contact

Insurance Information

Medical History (Select / Describe)

Consent for Treatment

I, the undersigned, authorize the practitioners and staff of the provider to perform those diagnostic and therapeutic procedures as are judged necessary or advisable in the course of my care, including routine examinations, diagnostic testing, medications, and minor procedures. I understand that no guarantee has been made as to the results of any treatment.

I have been informed of the nature and purpose of the proposed care, potential risks and complications, and reasonable alternatives. I understand that I may withdraw this consent at any time by notifying the provider, subject to reasonable notice and except where withdrawal would jeopardize safe care.

Consent to Treatment: I consent to the treatment described above and to such additional care as deemed necessary.

HIPAA Authorization & Privacy Acknowledgment

I acknowledge receipt of the provider's Notice of Privacy Practices and understand my rights regarding the use and disclosure of my protected health information. I authorize the provider to use and disclose my health information as necessary for treatment, payment, and healthcare operations, and as otherwise permitted or required by law.

Authorization to Release Information: I authorize the release of my medical records, including summary information, to the following person(s) or organization(s): for the purpose of continuity of care, claims adjudication, and coordination of benefits.

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 upon it. Certain disclosures made pursuant to this authorization may no longer be protected by federal privacy laws and could be subject to re-disclosure.

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

Financial Responsibility & Assignment of Benefits

Assignment of Benefits and Payment Agreement: I authorize and request payment of benefits to the provider for services furnished to me. I accept responsibility for deductibles, co-payments, co-insurance, and amounts not paid by my insurer. I agree to pay all reasonable collection and legal fees incurred in collection of overdue accounts.

I authorize payment directly to the provider and assign eligible insurance benefits for services rendered.

Telehealth / Electronic Communications Consent

Telehealth: I consent to receiving healthcare services via telehealth where clinically appropriate. I understand telehealth has limitations and that the provider will determine its appropriateness.

Electronic Communications: I consent to receive appointment reminders, test results, and billing communications via phone, text, and email as indicated above.

Certification and Signature

Certification: I certify that the information I have provided on this form is true and correct to the best of my knowledge. I understand that knowingly providing false information may subject me to civil or criminal penalties and may result in denial of coverage or services.

I understand that by signing below I am indicating my informed consent to the statements and authorizations contained in this document. I understand that this signature is also my authorization for release of information and assignment of benefits as indicated above.

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