Healthcare CPSE Packet

Healthcare CPSE Packet

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance Information

Medical & Developmental History

Immunizations up to date:

Consent for Evaluation and Treatment

I, the undersigned, authorize clinicians and authorized staff to perform clinical evaluations, assessments, and to provide medically indicated treatment and interventions as reasonable and necessary for diagnostic and therapeutic purposes. This authorization includes developmental screening, psychological assessment, speech/language evaluation, occupational therapy assessment, medical examination, and related services described in the service plan.

Purpose of evaluation/services:

I understand that participation is voluntary, that I may withdraw consent at any time by providing written notice, and that withdrawal will not affect services received prior to the withdrawal except as allowed by law. Withdrawal of consent will not limit providers from taking emergency action if necessary to prevent harm.

Risks, Benefits, and Alternatives

The expected benefits of evaluation and treatment include improved diagnosis, treatment planning, and access to appropriate services. Risks may include emotional discomfort, fatigue, or the need for additional evaluation. Reasonable alternatives to the recommended assessments or interventions will be explained upon request.

Authorization to Obtain and Release Medical Records

I authorize the release and exchange of protected health information, including summaries, assessments, treatment plans, and progress notes, between the healthcare team and other entities involved in care coordination for the purpose of evaluation, treatment, eligibility determinations, or care planning.

This authorization will expire on: . If no date is entered, authorization expires one year from signature date unless otherwise specified by law.

HIPAA Privacy Acknowledgment

I acknowledge receipt of the facility's Notice of Privacy Practices describing how my protected health information may be used and disclosed and how I may access this information. I understand the exceptions to confidentiality: providers may disclose information without authorization when required by law to report suspected abuse or neglect, when there is a serious threat to health or safety, or pursuant to a court order.

I authorize the release of information related to HIV status, mental health, substance use, or other sensitive health information when such information is necessary for treatment, payment, or healthcare operations as permitted by law.

I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance on it. To revoke, submit a written revocation to the facility's medical records office.

Additional Consents & Notices

Consent to share information with educational or service providers for care coordination:

Consent for audio/video recording for clinical review or training (only with explicit indicated purpose):

Provider / Referral Information

Certifications and Acknowledgments

By signing below I certify that the information I have provided is true and accurate to the best of my knowledge. I understand that providing false information may affect eligibility for services. I consent to the assessments and releases herein and understand my rights related to confidentiality and revocation as described above.

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