Healthcare Clinical Acknowledgment

HEALTHCARE CLINICAL ACKNOWLEDGMENT

Patient Name:     Date of Birth:

Patient Information

Emergency Contact

Insurance Information

Medical History (Relevant)

Clinical Acknowledgment and Authorizations

By signing below I certify the following statements are true and accurate to the best of my knowledge and that I have read and understand the clinical policies stated herein:

I consent to receive clinically indicated assessment and treatment, including examinations, routine diagnostic testing, and therapies determined necessary by my treating clinician. I understand that no specific treatment can be guaranteed and that all medical interventions carry potential risks.

I have been informed of the anticipated benefits, common risks, and alternative treatment options relevant to my care. I have had the opportunity to ask questions and those questions have been answered to my satisfaction.

I acknowledge receipt of the practice's 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 medical information, including records and billing information, to my insurance carrier and other entities as necessary for claims processing and care coordination. I authorize payment of benefits to the treating provider when applicable.

I understand I am financially responsible for charges not covered by my insurer and for any portions of charges denied or determined to be patient responsibility.

I understand I may revoke this authorization at any time by providing a written notice to the practice, except to the extent that action has already been taken in reliance on this authorization. I understand this authorization will expire on:

I understand that refusal to sign this acknowledgment may affect my ability to receive certain elective services and that emergency care will be provided irrespective of this acknowledgment.

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