Healthcare Consent & Benefit Form

HEALTHCARE CONSENT & BENEFIT FORM

Patient Information

Date of Birth:    Gender:    SSN (last 4 digits):

Home Phone:    Mobile Phone:

Relationship:    Phone:

Insurance Information

Policy Number:    Group Number:    Subscriber Name:

Subscriber DOB:    Insurance Phone:

Medical History

Primary Care Physician:    Office Phone:

Consent for Treatment and Assignment of Benefits

I, the undersigned patient or authorized representative, hereby authorize the healthcare providers and staff of the treating facility to provide medical and diagnostic services as deemed necessary. I acknowledge that the proposed care has been explained, including the anticipated benefits, material risks, and reasonable alternatives where applicable. I understand that no guarantee has been made regarding the outcome of treatment.

Description of intended treatment/procedure (brief):

By signing below I expressly authorize the provider to: (1) perform such diagnostic and therapeutic services as are necessary; (2) obtain and release medical information necessary for treatment, payment, or health care operations; and (3) communicate with my identified insurers and representatives regarding claims and benefits.

Authorization to Release Information & Privacy Acknowledgment

I authorize the release of my protected health information to the persons and entities involved in my care, and to my insurance carriers for the purpose of payment and case management. This authorization includes release of medical records, diagnostic images, and billing information as required. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy law.

I acknowledge receipt of the facility's Notice of Privacy Practices and understand my rights under applicable privacy laws, including the right to request restrictions on certain uses and disclosures of my health information. I understand I may revoke this authorization at any time by submitting a written revocation, except to the extent that action has already been taken in reliance on this authorization.

This authorization is valid until: . If no date is provided, this authorization will expire one year from the date of signature.

Billing, Payment and Certification

I certify that the information provided on this form is true and complete to the best of my knowledge. I understand that I am responsible for payment of services not covered by insurer(s), including deductibles, co-payments, coinsurance, and services determined non-covered. I authorize payment of benefits directly to the provider when allowed by my insurer.

I understand that providing false information to obtain payment or services may subject me to civil and criminal penalties. I authorize the provider to obtain payment directly from any liable third party, including but not limited to an insurer or administrator.

Patient Certifications & Notices

By signing below I certify that I have read and understand this Consent & Benefit Form, that I have been given the opportunity to ask questions and receive answers, and that I consent to the uses and disclosures described herein. I further certify I have either provided accurate insurance information or will notify the provider of changes.

I understand that I may request a copy of this signed authorization and that a photocopy or electronic copy of this document shall be as valid as the original.

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