Healthcare CS&HIPAA Form

HEALTHCARE CS & HIPAA FORM

Patient Information

Date of Birth:    Gender:

Home Phone:    Cell Phone:

Relationship:    Phone:

Insurance Information

Subscriber Name:    Policy/ID #:    Group #:

Medical History

Current Medications (name, dose, frequency):

Allergies (medications, latex, food, other):

Prior surgeries / hospitalizations (include year and procedure):

Chronic conditions (check all that apply):

Diabetes    Hypertension    Heart disease

Asthma/COPD    Kidney disease    Other (describe below)

Consent for Treatment

I, the undersigned, authorize the healthcare providers and staff of this practice to provide medical care, diagnostic tests, treatments and procedures as deemed necessary for my care. I consent to the performance of the following service(s) or procedure(s):

I understand that the practice has explained the nature and purpose of the proposed treatment, the risks and potential complications, expected benefits, and reasonable alternatives including the option of no treatment. I acknowledge that no guarantee or assurance has been made as to the results of any procedure. I have had the opportunity to ask questions and all my questions have been answered to my satisfaction.

I understand that I have the right to refuse or withdraw consent at any time prior to treatment, except where treatment has already been initiated. In the event of an emergency, I authorize the staff to provide such care as is necessary to stabilize my condition.

I consent to care through telehealth modalities where clinically appropriate.

HIPAA Authorization to Use and Disclose Protected Health Information (PHI)

I authorize this practice to use and disclose my protected health information as described below. This authorization is voluntary and is not required to obtain treatment, payment, or enrollment in a health plan.

Specific types of information to be disclosed (check all that apply):

Medical records and clinical summaries    Billing and insurance information

Radiology images and reports    Laboratory and test results

Mental health or psychotherapy notes (explicit consent)    Substance use treatment records (explicit consent)

I understand that if the person or organization receiving the information is not a health care provider or health plan covered by federal privacy protections, the information described above may be re-disclosed and no longer protected by federal law, although state law may apply.

I understand that I may revoke this authorization at any time by submitting a written notice to the practice, except to the extent that action has already been taken in reliance on this authorization. This authorization will expire on:

I understand that I will receive a copy of this authorization upon request and that signing this form is not a condition of receiving treatment, enrollment, or eligibility for benefits unless the purpose is to obtain insurance coverage.

Financial Responsibility & Acknowledgments

I accept financial responsibility for services provided and understand that I am responsible for any charges not covered by my insurer. I authorize release of information necessary to process insurance claims and assign benefits to the provider when applicable.

I acknowledge that I have been offered or provided the practice's Notice of Privacy Practices and that I have had the opportunity to ask questions regarding my privacy rights.

Additional Authorizations / Instructions

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