Healthcare Duplicate Intake Package

HEALTHCARE DUPLICATE INTAKE PACKAGE

Patient Information

Patient Name:

Female    Male    Non-binary    Other

Emergency Contact

Insurance Information

Medical History

Chronic Conditions (check all that apply):

Diabetes    Hypertension    Asthma / COPD    Heart disease    None of the above

Duplicate Records & Release Authorization

I authorize the release of duplicate copies of my medical records, including but not limited to treatment notes, diagnostic reports, imaging, and billing records, as necessary to facilitate continuity of care or at my request. Copies may be released to the following recipient(s):

This authorization applies to duplicates of the entire medical record or the following specific sections (check as applicable):

Progress notes    Laboratory reports    Imaging studies    Billing records    Entire record

Limitations and Fees: I understand that copies of medical records may be subject to reasonable reproduction fees where permitted by law. This authorization does not permit re-disclosure by the recipient if federal or state law prohibits further disclosure; however, the recipient may re-disclose to the extent allowed by law. I understand that refusal to sign this authorization will not affect my ability to obtain treatment, payment, or enrollment/eligibility for benefits, unless the information is required to determine those matters.

Consent for Treatment and Certifications

I hereby consent to routine medical treatment and diagnostic procedures performed by the facility's clinicians as deemed necessary for my care. I acknowledge that I have been provided an opportunity to ask questions about my care. I certify that the information provided on this intake package is true and complete to the best of my knowledge. I understand that knowingly providing false information may result in denial of service and may be subject to applicable penalties.

Right to Revoke: I understand that I may revoke this authorization at any time by submitting a written revocation to the facility, except where action has already been taken in reliance upon this authorization. Revocation will not affect disclosures already made based on this authorization.

Redisclosure: I understand that information disclosed pursuant to this authorization may include sensitive information and may be subject to redisclosure by the recipient. Information protected by specific state or federal law (such as substance use, mental health, or HIV-related information) will be disclosed only if I specifically authorize such disclosure by initialing here:

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 acknowledge that I have received and reviewed the Notice of Privacy Practices.

Additional Authorizations / Notes

By signing below I certify that I am the patient or am authorized to act on behalf of the patient and that I have legal authority to execute this document. I understand the nature and effect of this authorization and consent to the release of duplicate records as indicated above.

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