Healthcare Clinics LLC Form

HEALTHCARE CLINICS LLC FORM

Patient Information

Patient Name:

Month: Day: Year:

Male Female Other / Prefer not to say

Emergency Contact

Insurance Information

Medical History

No known allergies Allergies described below

Consent for Treatment

I, the undersigned patient or legal representative, hereby authorize Healthcare Clinics LLC and its authorized clinicians and staff to provide medical evaluation, diagnostic procedures, treatment, and ancillary services as deemed necessary in the professional judgment of the treating providers. I understand that treatment may include but is not limited to examinations, injections, minor procedures, laboratory testing, imaging, and administration of medications.

I have been informed of the nature of the proposed care, the expected benefits, and the reasonably foreseeable risks and complications associated with the recommended services. I understand that no guarantee or assurance has been made concerning the results of treatment. I have the right to ask questions and to refuse or withdraw consent at any time prior to the initiation of a procedure or treatment without affecting my future care.

HIPAA Privacy Acknowledgment & Authorization

I acknowledge that I have been offered the Notice of Privacy Practices that explains how Healthcare Clinics LLC may use and disclose my protected health information. I understand that I may request restrictions on certain uses and disclosures and that such requests will be considered by the clinic in accordance with applicable law.

Authorization to Release Information: I authorize Healthcare Clinics LLC to release my medical information to the following person(s) or organization(s) for the purpose(s) indicated. I understand that this authorization is voluntary and may be revoked in writing except to the extent action has been taken in reliance on it.

Patient Rights: I understand I may revoke this authorization at any time by submitting a written request, except to the extent that action has already been taken in reliance on this authorization. I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected under federal privacy regulations.

Financial Responsibility & Assignment of Benefits

I agree to be financially responsible for all charges for services provided to me that are not covered by my insurance. I authorize and direct payment of medical benefits to Healthcare Clinics LLC for services rendered. I understand that I am responsible for copayments, deductibles, coinsurance, and non-covered services as determined by my plan.

Consent for Telehealth (if applicable)

I consent to the use of telehealth technologies for my care when offered by my provider. I understand the limitations and risks of telehealth, including potential technical failures, and I may withdraw consent at any time without affecting my access to in-person care.

Telehealth Consent: I consent to telehealth services

Certification

By signing below I certify that the information I have provided on this form is true and complete to the best of my knowledge. I understand that intentionally providing false information may be grounds for denial of treatment. I authorize Healthcare Clinics LLC to communicate with the persons listed and to release medical information for purposes described above and for billing and payment purposes as necessary.

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