Healthcare Disclosures

HEALTHCARE DISCLOSURES

Patient Name:     Date of Birth:     Gender:

Patient Information

Insurance Information

Medical History (Relevant)

Disclosures and Acknowledgments

Use and Disclosure of Protected Health Information: I understand that my provider may use and disclose protected health information (PHI) for purposes of treatment, payment, and health care operations. PHI may be disclosed to other health care professionals, insurance carriers, billing agents, and as otherwise required or permitted by law, including reporting to public health authorities, mandatory reporting and court orders. I acknowledge that I have been provided an opportunity to review the provider's privacy practices and that disclosures not related to treatment, payment or health care operations will be made only with my written authorization except as required by law.

Disclosure to Family, Friends, and Caregivers: I authorize the provider to share relevant portions of my medical information with family members, friends, or other designated persons involved in my care as identified below. I understand that such disclosures are limited to the minimum necessary information to accomplish the purpose of the disclosure.

Electronic Communications and Messaging: I consent to receiving appointment reminders, billing notices, test results and other health-related communications via phone call, voicemail, SMS/text message, and email at the contact information I have provided. I understand that electronic communications may be intercepted and are not free from risk. I may revoke this consent in writing at any time, except to the extent that action has already been taken in reliance on this consent.

Check to permit electronic communications (phone/SMS/email) for appointments, billing, and clinical communications.

Assignment of Benefits and Financial Responsibility: I authorize payment of medical benefits to my provider for services rendered. I am financially responsible for charges not covered by insurance, including deductibles, co-payments, co-insurance, and services denied by my insurer. The provider may share billing and collection information with contracted agents as necessary to obtain payment.

I acknowledge financial responsibility for services rendered and assignment of benefits where applicable.

Photographs, Audio or Video Recordings: I authorize the provider to take and use photographs, audio or video recordings of me for treatment, identification, medical records and quality assurance. Any other use, including marketing or public release, will require a separate written authorization.

Research, Teaching and Quality Activities: My de-identified information may be used for research or teaching purposes. I understand that such use will not identify me by name without my separate written authorization and that participation in research is voluntary and will not affect my access to treatment if I decline to participate.

Special Categories of Information: Certain medical information (such as substance use treatment records, mental health notes, HIV-related information, or genetic testing results) may receive additional protections under law. Except where disclosure is required or permitted by law, such information will not be released without my explicit written authorization.

Authorization to Release Information

I hereby authorize the release of my medical information as described above to the authorized individuals and organizations identified herein. This authorization includes release of records necessary for treatment, billing, and continuity of care, and applies to both physical and electronic records unless limited below.

Right to Revoke: I understand that I may revoke this authorization at any time by providing a written notice to the provider. Revocation will not apply to disclosures already made in reliance on this authorization prior to receipt of my revocation. I understand that treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing this authorization except where permitted by law.

Required Disclosures Without Authorization: I acknowledge that the provider may disclose my PHI without my authorization when required by law, for public health reporting, to avert a serious threat to health or safety, in response to court orders or subpoenas, for law enforcement purposes as permitted by law, or to comply with mandatory reporting obligations.

I acknowledge that I have been offered a copy of the provider's Notice of Privacy Practices and have been informed of my rights regarding my protected health information.

Patient Certification and Signature

By signing below I certify that the information provided on this form is true and correct to the best of my knowledge. I have read and understand the disclosures above. I authorize release of my health information as indicated and accept financial responsibility as described. I understand my rights to revoke this authorization, the limits to confidentiality described herein, and the ability to request restrictions on disclosures.

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