Healthcare Client Check-Up Scope

Healthcare Client Check-Up Scope

Clinic Name:   Provider Name:

Client Name:   Visit Date:

1. Patient Information

2. Insurance Information

3. Medical History & Current Status

Primary Care Provider:

4. Check-Up Scope — Services to Be Performed

The following services will be included in the routine check-up unless declined by the client. Please mark consent where indicated.

  Measurement of vitals (blood pressure, pulse, respiratory rate, temperature)

  Focused physical examination relevant to presenting complaints

  Blood draw for routine labs (CBC, metabolic panel, lipid panel) — Consent to draw blood:

  Urinalysis — Consent:

  Immunizations/boosters as indicated — Client to be informed prior to administration

  Screening tests (vision, hearing, depression screening, BMI)

  Referral to specialist or diagnostic imaging if indicated

5. Limitations, Risks, Benefits, and Alternatives

The client understands that routine check-up services are intended for screening and early identification of medical issues. Tests and procedures performed are intended to inform diagnosis and treatment planning. Although risks associated with routine examinations and common diagnostic tests (e.g., minor discomfort with blood draw, transient bruising, allergic reaction to immunizations) are generally low, no procedure is entirely without risk.

Alternatives to any recommended test or treatment will be discussed on request. The client has the right to refuse any portion of the services listed above. Refusal will be documented and will not affect the provision of other services not declined, except where refusal creates a material risk to safe care.

6. Billing, Payment, and Authorization to Release Information

The client authorizes the clinic to bill the insurance identified above for services rendered. The client remains financially responsible for charges denied by the insurer, for co-payments, deductibles, and for services not covered by insurance.

By signing below, the client authorizes the release of medical information necessary for treatment, payment, and health care operations to the insurer and other providers involved in care, except as restricted in writing by the client.

7. HIPAA Acknowledgement and Authorization

I acknowledge that I have received or been offered the clinic's Notice of Privacy Practices describing how protected health information may be used and disclosed. I authorize the clinic to use and disclose my protected health information for treatment, payment, and healthcare operations as described in that notice.

This authorization permits release of information to other healthcare providers, insurers, and entities as necessary for continuity of care and billing. I understand I may revoke this authorization in writing at any time, except where actions have already been taken in reliance on this authorization.

  I acknowledge receipt/offering of the clinic's Notice of Privacy Practices

Authorization Expiration Date:

8. Provider Assessment / Planned Follow-Up

9. Client Certification and Consent

By signing below, I certify that the information I have provided is true and accurate to the best of my knowledge. I consent to the provision of the services indicated above. I understand the nature of the services, the expected benefits, and the most common risks. I understand that I may withdraw consent at any time by providing written notice to the clinic, except to the extent that action has already been taken in reliance on my prior consent.

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