Healthcare Exam Documents

HEALTHCARE EXAM DOCUMENTS

Patient Information

Patient Name:

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History

Presenting Complaint and Exam

Height:    Weight:    Blood Pressure:

Pulse:    Temperature:    Respiratory Rate:

Consent for Examination and Treatment

I hereby authorize the attending clinician and authorized clinical staff to perform the physical examination, diagnostic testing, and routine procedures necessary to evaluate and treat my condition. I understand that risks and benefits vary by procedure and that reasonable efforts will be made to inform me of significant risks and alternatives prior to non-emergent procedures.

I acknowledge that I have the right to ask questions, to refuse treatment, and to withdraw consent at any time, except when withdrawal would jeopardize my health or when treatment is required by law to prevent imminent harm.

By checking the box below I consent to evaluation and treatment as indicated by the clinician and acknowledge that this consent applies to routine diagnostic procedures and minor invasive procedures customary to outpatient examination.

I consent to examination and treatment

HIPAA / Privacy Authorization

I acknowledge receipt of the facility's Notice of Privacy Practices describing how my protected health information may be used and disclosed for treatment, payment, and healthcare operations. I understand that I may request restrictions on certain uses and disclosures.

I authorize the release of my health information to the extent necessary for treatment, payment, and healthcare operations, including communications with my insurance carrier and other healthcare providers involved in my care.

I acknowledge the Notice of Privacy Practices and authorize necessary disclosures

Release of Records (Optional)

I authorize the release of my complete medical record, including history, diagnoses, laboratory and imaging results, and other relevant information to the recipient named below for the purpose indicated.

I authorize release of records as described above

Patient Certification and Financial Responsibility

I certify that the information I have provided is true and correct to the best of my knowledge. I accept financial responsibility for charges incurred for services rendered and agree that I am responsible for payment in accordance with facility and provider policies.

I authorize payment of insurance benefits to the provider for services rendered when applicable and understand that I remain responsible for any portion not covered by insurance.

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