Healthcare Certificate of Compliance

HEALTHCARE CERTIFICATE OF COMPLIANCE

Issuing Facility

Patient Information

Date of Birth:    Gender:

Primary Phone:    Emergency Contact:    Emergency Phone:

Insurance Information

Policy Number:    Group Number:

Medical History & Current Status

Compliance Declarations (Patient Attestation)

I, the undersigned, certify that the information provided in this Certificate of Compliance is true, complete, and accurate to the best of my knowledge. I understand that the facility will rely on this certification in delivering medical care and determining readiness for procedures.

By selecting each applicable box below I affirm compliance with the stated requirement as of the date of signature.

I am in compliance with pre-procedure fasting and preparation instructions provided by the facility.

I have disclosed all medications and am compliant with medication adjustments required for care.

I have provided accurate immunization records requested by the facility (including influenza and COVID-19 if required).

I will comply with infection control practices, including screening and masking requirements as applicable.

I have provided any advance directive, living will, or proxy designation to be included in my medical record.

HIPAA & Privacy Acknowledgment

I acknowledge that I have received or been offered a copy of the facility's Notice of Privacy Practices describing how my protected health information may be used and disclosed and how I can access this information. I understand that the facility may use my information for treatment, payment, and health care operations as described in that Notice.

I acknowledge receipt of the Notice of Privacy Practices.

Certifications and Legal Terms

The patient certifies that all statements made herein are accurate. False statements or omissions material to the delivery of care may be grounds for suspension of services, denial of coverage by insurers, or other lawful action. The patient authorizes the facility to verify the information provided and to obtain records from other providers as reasonably necessary to confirm compliance and to deliver appropriate care.

This Certificate of Compliance does not waive or limit any rights of the patient or the facility under applicable law. The facility retains the right to perform independent assessments and to require corrective action if it reasonably determines that compliance is not met. The patient may revoke or amend this certification in writing; such revocation does not affect disclosures or actions taken in reliance on this certificate prior to receipt of the revocation.

By signing below, the patient attests under penalty of perjury under applicable law that the foregoing is true and correct and consents to the uses and disclosures described above.

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