Healthcare Compliance Packet

HEALTHCARE COMPLIANCE PACKET

This packet collects patient-identifying information, clinical history, insurance and financial acknowledgments, privacy consents and authorizations required for treatment, billing, and the release of protected health information. Patient Name: Date of Birth:

Patient Information

Emergency Contact

Insurance Information

Medical History

Consent for Treatment

I authorize the medical staff to provide diagnostic and therapeutic care as is necessary in their professional judgment. I understand that the practice will explain proposed procedures, material risks, expected benefits and reasonable alternatives. I have the right to ask questions and to refuse any treatment. By checking the box below and signing this packet I give my informed consent for routine diagnostic tests, examinations, and treatments associated with my care.

Privacy, HIPAA Acknowledgment & Authorization

I acknowledge that I have received or been offered a copy of the facility's Notice of Privacy Practices describing how my protected health information may be used and disclosed. I understand that this authorization permits the release of my protected health information for purposes of treatment, payment and healthcare operations unless otherwise restricted below.

Authorization to Release Medical Information: I authorize the practice to release my medical records, including protected health information, to designated individuals or entities for purposes of continuity of care or billing. This authorization will remain in effect until the date indicated below or until I revoke it in writing.

Financial Responsibility & Assignment of Benefits

I authorize assignment of insurance benefits to the provider. I understand that I am responsible for charges not covered by my insurance, including copayments, deductibles, non-covered services, and charges resulting from inaccurate insurance information. I agree to reimburse the provider for collection costs and reasonable attorney fees if my account is referred for collection.

Release of Information for Billing

Advance Directives

Do you have an advance directive, living will, or durable power of attorney for healthcare?

Patient Certification

I certify that the information provided in this packet is true and accurate to the best of my knowledge. I understand that knowingly providing false information may affect my eligibility for benefits and may subject me to penalties. I understand my rights to privacy and that I may revoke authorizations in writing except to the extent that action has already been taken in reliance on this authorization.

I further acknowledge that I have been given the opportunity to ask questions regarding my treatment, financial obligations, and privacy rights, and that my signature below constitutes informed consent to the items checked in this packet and authorization necessary for treatment, billing and the release of information as indicated.

Sign Now