Healthcare FDD Form

HEALTHCARE FDD FORM

Patient Information

Patient Name:

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Policy Number:    Group Number:

Subscriber Date of Birth:    Insurance Phone:

Medical History

Financial Disclosure & Responsibility

Guarantor / Responsible Party:

Relationship to Patient:    Annual Household Income:

Insurance billed as primary    Self-pay / Cash    Medicaid    Medicare    Other

By signing this form the undersigned certifies that all insurance and financial information provided is true and complete. The undersigned authorizes assignment of benefits to the facility/provider and authorizes release of medical information necessary to process claims. The undersigned accepts responsibility for charges not paid by insurance, including co-payments, deductibles, coinsurance, and balances resulting from denied claims. Failure to pay amounts due may result in collection activity and reporting to credit agencies.

HIPAA Authorization & Privacy Acknowledgment

I acknowledge receipt of the provider's Notice of Privacy Practices and understand that my protected health information may be used and disclosed for treatment, payment and healthcare operations. I authorize the release of health information as necessary for billing and claims adjudication. This authorization is voluntary and may be revoked in writing, but revocation will not apply to disclosures made prior to receipt of the revocation.

I acknowledge and consent to the uses and disclosures described above.

Authorization to Release Medical Records

Authorization Expiration Date:

I authorize the release of the above-specified medical information to the recipient listed for the stated purpose until the expiration date.

Consent to Treatment

I consent to medically necessary examination, diagnostic procedures, and treatment by the provider and staff. I have been informed of the nature and purpose of the proposed care, known risks and benefits, and reasonable alternatives. I understand I may withdraw consent at any time by providing written notice, except to the extent that the provider has already acted in reliance on my consent.

I consent to treatment as described above.

Certification and Attestation

By signing below I certify that the information provided on this Healthcare FDD Form is true and complete to the best of my knowledge. I understand that knowingly providing false information may subject me to civil or criminal penalties. I authorize communication by telephone, text message, and mail regarding appointments, treatment, and billing unless I provide written notice to restrict such communications.

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