Healthcare DC Forms

HEALTHCARE DC FORMS

Facility Name:    Date of Visit:

Patient Information

Date of Birth:    Gender: Male Female Other

Emergency Contact

Insurance Information

Medical History

Consent for Treatment

I, the undersigned, authorize the licensed healthcare providers, employees and agents of the facility named above to perform diagnostic procedures, medical and surgical treatments as deemed necessary by such providers. I understand that no guarantee has been made as to the results of any treatment.

I acknowledge that I have had the opportunity to ask questions about the proposed care and alternatives, that my questions have been answered, and that I may withdraw this consent at any time prior to the procedure by notifying the provider in writing, except where the provider has already commenced treatment.

By checking this box I consent to the above treatment and to administration of such anesthetic agents and medications as deemed necessary.

HIPAA Authorization and Privacy Acknowledgment

I acknowledge that I have received the facility's notice of privacy practices describing how my protected health information (PHI) may be used and disclosed. I authorize the facility to use and disclose my PHI for treatment, payment, and health care operations as set forth in that notice and as permitted or required by law.

I authorize the facility to disclose my PHI to the following individual(s) or organization(s) for the purpose(s) indicated:

This authorization, unless earlier revoked in writing, expires on: . I understand that I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance on it.

I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations.

Treatment information
Billing and insurance information
Laboratory and diagnostic reports
Full medical record

Release of Medical Records

I hereby authorize the release of my medical records as described below in accordance with applicable law. I understand that certain sensitive records (for example, psychotherapy notes, substance use disorder treatment records, or HIV-related information) may require specific authorization; if such records are included I have indicated so below.

Expiration of Authorization: . If no date is provided, this authorization will expire one year from the date signed unless a shorter period is required by law.

I understand that a fee may be charged for copying and postage in accordance with applicable law and that payment of such fees is required before records will be released unless otherwise agreed.

Financial Responsibility and Assignment

I agree to be financially responsible for any charges for services not covered by insurance or for which my insurance denies payment. I authorize payment of benefits to the provider for services rendered and assign to the provider all rights and benefits payable under my policy for services provided.

By checking this box I acknowledge the financial responsibility and assignment of benefits statement above.

Acknowledgments

By signing below I certify that the information provided on this form is true and accurate to the best of my knowledge. I further certify that I have the legal authority to sign this form. If I am signing on behalf of the patient, I certify that I am the patient's legal guardian or authorized representative and I will provide documentation of that authority if requested.

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