Healthcare Choice List

HEALTHCARE CHOICE LIST

Patient Information

Patient Name:

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History (brief)

Care & Treatment Preferences

I consent to routine medical treatment and recommended preventive care.

I authorize treatment in the event of an emergency when I cannot provide verbal consent.

I have an advance directive on file with this provider.

Communication Preferences

How may we contact you about appointments, test results, and care?

Phone calls to primary number

Text messages (SMS)

Email

Secure patient portal messaging

Release of Information

Indicate which persons or entities may receive your protected health information (PHI).

Release information to family members involved in my care.

Release information to the named individuals listed below.

Permit use of de-identified information for research and quality improvement.

Authorize release of mental health treatment records.

Authorize release of substance use treatment records.

Telehealth & Special Care Preferences

I consent to receive care via telehealth where clinically appropriate.

I do not consent to telehealth visits at this time.

Immunization & Pain Management Choices

I accept recommended immunizations and vaccinations as clinically indicated.

I decline one or more immunizations; see notes below.

Pain management preference:

Prefer non-opioid pain management when clinically appropriate.

Accept opioid therapy if deemed medically necessary.

Research & Future Contact

I agree to be contacted for future health-related research or surveys (contact limited to information I authorize).

HIPAA & Acknowledgment

I acknowledge that I have been offered the provider's privacy practices notice and that I understand how my health information may be used and disclosed under those practices.

By completing and signing this Healthcare Choice List I authorize the uses and disclosures of my protected health information as indicated above. I understand that I may revoke this authorization at any time by providing a written notice to my provider, except to the extent that action has already been taken in reliance on this authorization. I understand that information disclosed pursuant to this authorization may include sensitive information, including mental health treatment records and substance use treatment records where I have authorized those disclosures. I understand that refusal to sign this form will not affect my ability to obtain treatment, except where permitted by law and policy.

I further understand that this authorization will remain in effect until the expiration date indicated above, or until I revoke it in writing, whichever occurs first.

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