Healthcare DC Paperwork

HEALTHCARE DC PATIENT INTAKE, CONSENT & AUTHORIZATION

Patient Information

Date of Birth:    Gender: Male Female Other

Insurance Information

Medical History

Tobacco use: Current Past    Alcohol use: Yes No    Pregnancy (if applicable): Pregnant

Consent for Treatment

I, the undersigned, authorize licensed clinicians and staff of this practice to perform examinations, diagnostic procedures, therapeutic treatments, injections, imaging, and other outpatient services as clinically indicated. I understand that all care will be explained to me, including the nature of the recommended procedure(s), anticipated benefits, material risks, and reasonable alternatives, including the risks of refusing treatment.

I acknowledge that no guarantee has been made to me regarding the outcome of any treatment. I have had the opportunity to ask questions and all my questions have been answered to my satisfaction. I understand I may revoke this consent at any time prior to a procedure by notifying a clinician; revocation will not affect any actions already taken based on this consent.

Financial Responsibility & Assignment of Benefits

I accept financial responsibility for services rendered by this practice. I authorize the release of any medical or other information necessary to process claims and request payment of insurance benefits be made directly to the treating provider. I understand I remain responsible for charges not covered by insurance, including co-payments, co-insurance, deductibles, and non-covered services. Payment is due at the time of service unless other arrangements are made in writing.

For services billed electronically, I permit the practice and its billing agents to submit claims, corrections, and required attachments on my behalf. I authorize my insurer to pay benefits to the provider and to release information required to adjudicate claims.

HIPAA Authorization & Release of Medical Information

I acknowledge receipt of the provider's Notice of Privacy Practices and understand my rights regarding protected health information. By signing below I authorize the provider to use and disclose my protected health information for treatment, payment, and healthcare operations, and to release records to the following individual(s) or organization(s) as specified.

Authorization expiration date:    I authorize release of full medical record: Yes

Acknowledgements & Certifications

I certify that the information I have provided is accurate and complete to the best of my knowledge. I understand that providing false information may affect my care. I consent to telephone calls, text messages, and mailed communications from this practice for appointment reminders, billing notices, and health information unless I notify the practice in writing to restrict such communications.

I understand I may withdraw authorizations provided in this document at any time by submitting a written revocation, except to the extent that the practice has already relied upon my authorization. I understand that revocation will not affect disclosures made prior to receipt of the revocation.

Consent for automated messaging: I consent to receive SMS/text communications

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