Healthcare Confirmation of Services

Healthcare Confirmation of Services

Patient Information

Patient Name:    Date of Birth:

Gender: Female Male Other/Prefer not to say

Insurance Information

Medical History (Relevant)

Service Details

Date of Service:    Time:

Payment Responsibility: Insurance Self-pay / Patient Other

Consent and Authorizations

I authorize the provider and facility named above to perform the procedure(s) and provide the service(s) described. I acknowledge that the procedure(s) have been explained to me including the nature and purpose of the procedure(s), reasonably foreseeable risks and common complications, expected benefits, and reasonable alternatives including the option of no treatment. I have had the opportunity to ask questions and understand that no guarantee has been made to me as to the results.

I understand that I may withdraw this consent at any time prior to the initiation of the procedure by notifying the treating provider, except to the extent that the provider has already relied on this authorization. Withdrawal does not affect actions taken in reliance on this consent prior to receipt of notice of withdrawal.

Authorization to Release Information for Billing: I authorize the release of medical information necessary to process insurance claims and pursue payment, and hereby assign benefits to the provider for such payment. I understand that I remain financially responsible for charges not paid by my insurer, including deductibles, copayments, coinsurance, noncovered services, and services deemed not medically necessary.

Collection and Payment: If charges are not paid when due, I agree that the provider may seek payment by available legal means, and I accept responsibility for reasonable collection costs, attorney fees, and interest where permitted by law.

Privacy Authorization and Expiration

I acknowledge that I have been offered a copy of the provider's Notice of Privacy Practices and that my protected health information may be used and disclosed as described in that notice for treatment, payment, and healthcare operations. I specifically authorize the use and disclosure of my protected health information to my insurance carrier, third-party administrators, and their agents for the purpose of claim adjudication and payment.

This authorization will expire on:

Revocation: I understand I may revoke this authorization at any time by providing a written notice to the provider; however, revocation will not apply to information already released in reliance on this authorization prior to receipt of revocation.

Acknowledgments

By signing below I certify under penalty of perjury that the information provided on this form is true, complete, and correct to the best of my knowledge, that I have authority to sign on behalf of the patient if signing as an authorized representative, and that I accept the financial and legal responsibilities described above.

Acknowledgment of Receipt of Information: I acknowledge receipt of the Notice of Privacy Practices. I received an estimate of expected charges where applicable.

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