Healthcare Client Docs

HEALTHCARE CLIENT DOCS

Patient Information

Patient Name:

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History

Consent for Treatment

I, the undersigned, authorize the healthcare providers and their designated staff to perform the procedure(s) and provide any necessary medical treatment as described below. I understand that the practice of medicine and surgery is not an exact science and that no guarantees have been made to me regarding the results of any treatment or procedure.

Risks and Benefits: I have been informed of the anticipated benefits, significant risks, common complications, and reasonable alternatives related to the proposed treatment. I understand that risks may include but are not limited to infection, allergic reaction, bleeding, or other complications specific to the procedure. I acknowledge that no guarantees or assurances have been made regarding outcome.

I acknowledge that the risks, benefits, and alternatives have been explained to me and that I have had the opportunity to ask questions.

Right to Withdraw: I understand that I may withdraw this consent at any time prior to the procedure, except to the extent that action has already been taken in reliance on this consent.

I understand my right to refuse or withdraw consent and the consequences of doing so.

HIPAA Authorization & Privacy Acknowledgment

I acknowledge receipt of the Notice of Privacy Practices and understand how my protected health information may be used and disclosed for treatment, payment, and healthcare operations. I authorize the release of my health information for the purposes described in this document and to the persons or entities identified below as necessary for my care and billing.

I acknowledge receipt of the practice's Notice of Privacy Practices.

I authorize the provider to disclose my protected health information to the person(s) or entity named below for the purpose(s) indicated.

Expiration of Authorization: Unless earlier revoked in writing, this authorization will expire on the date specified below or automatically upon the following event: termination of care for this episode or upon written revocation.

Revocation: I understand I may revoke this authorization at any time by submitting a written notice to the Privacy Officer, 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 be subject to redisclosure by the recipient and no longer protected by federal privacy regulations.

Release of Medical Records (Optional)

I authorize release of my medical records as described below. This release is voluntary and will be used only as specified unless otherwise required by law.

Financial Responsibility & Assignment

I accept financial responsibility for services rendered that are not covered by my insurer or that my insurer denies. I authorize assignment of benefits to the provider for payment of covered services and release any necessary medical information to process claims.

I authorize direct payment of benefits to the provider and accept financial responsibility as described above.

Certification

By signing below, I certify that the information provided on this form is true and complete to the best of my knowledge. I authorize the healthcare provider to render medical care and to disclose my health information as described above. I understand that I may request a copy of this authorization for my records.

I certify that the information provided is accurate and that I have read and understand the statements above.

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