Healthcare Consult Packet

HEALTHCARE CONSULT PACKET

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Other/Non-binary

Emergency Contact

Insurance Information

Medical History

Tobacco Use: Current Former Never

Alcohol Use: None Social Regular

Consult Details

Date of Symptom Onset:    Referring Provider:

Consent for Evaluation and Treatment

I consent to evaluation, diagnostic testing, and treatment by the clinicians and staff of this practice. I understand that clinicians will explain the nature of proposed evaluations and treatments, potential benefits and risks, and reasonable alternatives. I understand that no guarantee has been made to me as to the results of any treatment or procedure.

I understand I may refuse or withdraw consent at any time, except where withdrawal of consent would jeopardize safety or violate legal or ethical obligations. I acknowledge that I have had the opportunity to ask questions and have those questions answered to my satisfaction.

Acknowledgement of Consent to Treat: I consent to evaluation and treatment as described above.

Privacy and HIPAA Authorization

I acknowledge receipt of the Notice of Privacy Practices describing how my protected health information may be used and disclosed. I understand that the practice will use and disclose my information for treatment, payment, and healthcare operations as described in the notice.

I authorize the release of my protected health information to other healthcare providers, insurers, and persons I designate when necessary for care coordination, billing, and treatment. This authorization includes the release of records related to mental health, substance use, and communicable disease unless I have specifically excluded such categories below.

Authorization Expiration:

I understand I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it. Revocation must be submitted in writing to the practice privacy officer.

Acknowledgement of HIPAA Authorization: I authorize the uses and disclosures described above.

Financial Responsibility & Assignment

I understand that I am financially responsible for all charges for services rendered to me that are not covered or paid by my insurer. If applicable, I assign benefits to the provider for services rendered and authorize payment directly to the provider. I agree to promptly notify the practice of any changes in my insurance coverage.

Assignment of Benefits: I assign payment of applicable benefits to the treating provider.

Consent to Release Records

I authorize the release of my medical records related to this consultation to the following individual(s) or entity(ies). This authorization is valid until the Authorization Expiration date above unless earlier revoked in writing.

Acknowledgments

By signing below I acknowledge that the information I have provided is true and accurate to the best of my knowledge. I understand that providing false information may affect my care and billing.

I have read and understand the terms above, including consent for treatment, HIPAA authorization, and financial responsibility.

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