Healthcare Comhs Form

Healthcare Comhs Form

Patient Name:    Date of Birth:

Patient Information

Male    Female    Other:    Prefer not to say

Emergency Contact

Insurance Information

Medical History

Primary Care Provider:    Phone:

Has the patient been hospitalized in the past 12 months?   Yes    No

Consent for Treatment

I authorize Comprehensive Health Services personnel to provide evaluation, diagnostic procedures, treatment, and medical services as deemed necessary for my care. I understand that treatment may include clinical assessment, minor medical procedures, medications, laboratory testing, and counseling as appropriate to the presenting condition.

I acknowledge that risks, side effects, and potential complications have been explained and that no guarantees have been made regarding outcomes. I understand my right to ask questions and to refuse any treatment. I may withdraw consent in writing at any time, except to the extent that action has already been taken in reliance on this consent.

I consent to necessary treatment: I consent

Authorization to Release / Obtain Medical Records

I authorize Comprehensive Health Services to obtain and/or release medical records and health information as necessary for treatment, payment, and healthcare operations to the individuals and entities specified below. This authorization includes medical history, laboratory results, imaging, and other records relevant to my care, including mental health and substance use treatment records unless I specifically limit them below.

Include the following sensitive records (check all that apply):   General medical   Mental health   Substance use treatment   HIV-related information   Genetic information

Authorization expiration date:

I understand that I may revoke this authorization at any time by delivering written notice to the healthcare facility, 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 may no longer be protected by federal privacy regulations.

HIPAA Privacy Acknowledgment

I acknowledge that I have received or been offered a copy of the Notice of Privacy Practices describing how my health information may be used and disclosed and how I can obtain access to this information. I understand my rights regarding protected health information and the facility's duties to protect that information.

I acknowledge receipt of Notice of Privacy Practices: Acknowledged

Financial Responsibility & Assignment

I understand that I am financially responsible for services provided by Comprehensive Health Services. I assign benefits and authorize payment of insurance benefits to the provider for services rendered. I agree to pay any balances not covered by insurance, including copayments, deductibles, and services not covered by my plan.

Assignment of benefits: I authorize payment of benefits to the provider

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 authorize the release of information necessary to process claims and to provide ongoing care. I understand that knowingly providing false information may be grounds for denial of services and may have legal consequences.

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