Healthcare Client Documents

HEALTHCARE CLIENT DOCUMENTS

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Other

Emergency Contact

Insurance Information

Medical History

Please indicate current or prior conditions (check all that apply):

Diabetes    Hypertension    Heart disease    Asthma / COPD

Kidney disease    Liver disease    Cancer    Mental health condition

Consent for Treatment

I, the undersigned, authorize physicians, nurses and other authorized personnel of this facility to provide evaluation, diagnostic tests, treatment and medical services deemed necessary for my care. I understand that no guarantee has been made to me regarding the results of any treatment or procedure.

I have been informed of the nature of the proposed treatment or procedure, the anticipated benefits, the reasonably foreseeable risks and potential complications, and alternative treatment options, including no treatment. I understand that I may withdraw consent at any time prior to the initiation of treatment, except where withdrawal would create a substantial risk to my health or safety.

Consent for anesthesia or sedation (if applicable): I consent to administration of anesthesia or sedation as indicated by clinical staff and described to me prior to the procedure.

Authorization to Release Protected Health Information

I authorize the release of my protected health information (PHI) as described below. I understand that information disclosed pursuant to this authorization may include records relating to medical history, mental health, communicable diseases, substance abuse, and HIV status where applicable.

Information to be disclosed: All medical records    Limited records (specify in Purpose)

This authorization will expire on:    or upon completion of the purpose specified above.

I understand that I may revoke this authorization at any time by delivering a written notice of revocation to the facility, except to the extent that action has already been taken in reliance upon this authorization.

HIPAA Privacy Acknowledgment

I acknowledge that I have been offered or received the Notice of Privacy Practices that describes how my protected health information may be used and disclosed and how I can access this information. I understand my rights with respect to my PHI and that I may request restrictions on certain uses and disclosures.

I acknowledge receipt of the Notice of Privacy Practices.

Financial Responsibility and Assignment of Benefits

By signing below, I authorize payment of benefits to the provider for services rendered and accept financial responsibility for charges not covered by insurance or otherwise payable by me. I agree to promptly notify the provider of any changes in my insurance coverage.

I assign insurance benefits to the provider and accept financial responsibility as described above.

Certifications

I certify that the information I have provided on this form is accurate and complete to the best of my knowledge. I authorize the release of information necessary to process claims and understand that falsification may subject me to penalties under applicable law. I have read and understand the consents, acknowledgments, and authorizations contained in this document.

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