Healthcare Comprehensive Program

HEALTHCARE COMPREHENSIVE PROGRAM

Program Enrollment — Patient Information

Patient Name:

Emergency Contact

Insurance Information

Medical History — Current Health Information

Program Scope, Risks and Benefits — Consent to Participate

I voluntarily seek enrollment in the Healthcare Comprehensive Program (the Program). I understand that the Program includes assessment, treatment planning, clinical services, and multidisciplinary coordination of care. Program components may include in-person clinical visits, group sessions, remote monitoring, telehealth, and referral to ancillary providers.

I acknowledge that the nature of services and interventions may present risks including, but not limited to, temporary discomfort, side effects from prescribed medications, or emotional distress. I have had an opportunity to discuss anticipated benefits and material risks with a Program representative and have had my questions answered to my satisfaction.

Program Start Date:

Consent to Participate: I hereby consent to participate in the Program and authorize Program staff to provide and coordinate care consistent with program objectives.

Authorization to Treat, Release of Records & Assignment of Benefits

By signing this form I authorize the Program, its employees, agents and contractors to provide medical, behavioral and ancillary services deemed necessary in the professional judgment of the Program clinicians. I authorize the release of medical information necessary for treatment, payment, and health care operations, including coordination with other covered providers and payors.

Assignment of Benefits: I assign to the Program all rights and benefits to which I am entitled for services rendered, including insurance and third-party payments. I agree to cooperate in securing payment and agree that any payments received shall be applied to my account.

Financial Responsibility: I understand I am responsible for applicable co-payments, deductibles, non-covered services and any fees not paid by insurance. Failure to pay may result in collection activity.

HIPAA Authorization and Privacy Acknowledgment

I acknowledge receipt of the Program's Notice of Privacy Practices and understand how my protected health information (PHI) will be used and disclosed for treatment, payment, and health care operations. I authorize the Program to use and disclose my PHI as described in the Notice, including communications with my designated emergency contact, other health care providers, payors, and for quality assurance and treatment coordination.

Authorization to Release Records to Other Providers: I authorize the Program to release or obtain medical records as necessary to coordinate my care and benefits.

Telehealth and Remote Monitoring Consent (Optional)

Telehealth: I consent to receive telehealth services as part of the Program where clinically appropriate. I understand limitations, benefits and privacy considerations associated with telehealth.

Emergency Care and Transportation

In the event of an emergency, I authorize Program personnel to arrange transportation and emergency medical treatment. I acknowledge that I remain responsible for emergency services and related charges.

Revocation and Right to Withdraw

Except as prohibited by law, I may revoke this authorization at any time by providing written notice to the Program's privacy officer. Revocation will not affect disclosures made in reliance on this authorization prior to receipt of revocation or where action has been taken in reliance on this authorization.

Acknowledgments and Declarations

I certify that the information provided on this form is true and complete to the best of my knowledge. I authorize the Program to communicate with the persons listed on this form and to contact me regarding appointments, billing, and care coordination.

Patient Initials:

Optional Designations

Sign Now