Healthcare Chartwell Form

HEALTHCARE CHARTWELL FORM

Patient Information

Emergency Contact

Insurance Information

Medical History

Consent for Treatment

I, , hereby authorize Chartwell healthcare providers and associated personnel to perform assessments, diagnostic procedures, and medically indicated treatment as deemed necessary. I understand that treatment may include examinations, medication administration, minor procedures, and diagnostic testing.

I acknowledge that no guarantee or warranty has been made as to the results of examinations or treatments. I have been informed of the reasonably foreseeable risks and benefits of the recommended care and have had the opportunity to ask questions and receive answers. I understand that I may withdraw consent at any time, except where withdrawal would jeopardize my health in an emergency.

I consent to the administration of medications and treatments as ordered by my attending clinician and to routine clinical photographs for medical documentation. I authorize staff to contact me at the phone number provided regarding appointment scheduling and care coordination.

HIPAA Authorization and Release of Information

I authorize Chartwell and its agents to use and disclose my protected health information for purposes of treatment, payment, and health care operations. This authorization includes, but is not limited to, disclosure to insurers, referring providers, pharmacies, and other entities involved in my care. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by privacy laws.

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. To revoke this authorization I must provide a written request to Chartwell's privacy office specifying the revocation and the date it should be effective.

Financial Responsibility and Assignment

I agree to be financially responsible for all charges for services rendered by Chartwell that are not paid by my insurance. I authorize assignment of benefits to Chartwell and direct my insurer to remit payment for covered services to Chartwell unless otherwise stated. I understand billed amounts may include co-payments, deductibles, and non-covered services.

I authorize the release of medical information necessary to process claims and to obtain payment. If payment is not received from the insurer, I am responsible for balances due.

Authorization Period and Expiration

This authorization is effective immediately upon my signature and will expire on unless I provide written revocation earlier.

Patient Rights Acknowledgment

I acknowledge that I have received, been offered, or been informed of the availability of the Chartwell Notice of Privacy Practices and have had the opportunity to ask questions regarding the use and disclosure of my health information. I understand my rights to access my medical records, request an amendment, and request restrictions on certain disclosures, subject to applicable law.

Additional Consents / Statements

Certification and Signature

By signing below I certify that the information provided on this form is true and accurate to the best of my knowledge. I understand that falsification or omission of material information may affect my care and coverage. I have read and understand the consents and authorizations herein and consent to treatment, release of information, and assignment as stated.

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