Healthcare Certification Page

HEALTHCARE CERTIFICATION PAGE

Patient Information

Date of Birth:    Gender:

Phone:    Email:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy / ID Number:    Group Number:

Subscriber Date of Birth:

Medical History

Is the patient currently able to provide informed consent? Yes

Certification and Authorization

I certify that I am the person named above, or I am the lawful guardian or authorized representative of the person named above. I certify under penalty of perjury that the information provided on this page is true, correct and complete to the best of my knowledge. Patient Name: Date of Birth:

I authorize the release of medical and other health information necessary to process claims, to coordinate care, and for quality review. This authorization includes release of records relating to mental health, substance use treatment, HIV/AIDS status, and other sensitive information unless specifically limited in writing below.

I authorize assignment of benefits for payment of medical services to the provider and permit release of medical information to payers for determination of eligibility and payment. I understand that I am financially responsible for charges not covered by insurance.

Permission to leave messages regarding appointments, test results, or billing at the phone number provided: Yes

HIPAA / Privacy Acknowledgment

I acknowledge that I have received or been offered a copy of the Notice of Privacy Practices describing how my protected health information may be used and disclosed, and my rights with respect to that information. I understand that I may request additional restrictions in writing, but that the provider is not required to agree to those restrictions.

Acknowledgment of Receipt of Privacy Notice: I acknowledge

This authorization expires on: . If no date is provided, this authorization will expire one year from the date of signature unless otherwise specified by applicable law.

Legal Notices

By signing below I acknowledge that I have read and understand the statements above. I understand that I may revoke this authorization at any time by providing written notice, except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect disclosures previously made in reliance upon this authorization.

If signing as a representative of the patient, I certify that I am the legally authorized representative and that documentation establishing such authority is available upon request.

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