Healthcare Group Paperwork

HEALTHCARE GROUP PAPERWORK

Patient Information

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History

Consent for Treatment

I hereby authorize licensed practitioners and staff of the practice to perform such diagnostic, therapeutic and procedural services as deemed necessary for my care. I understand that all treatments have potential risks and benefits, that no guarantees have been made regarding results, and that alternative treatments may be available. I have had the opportunity to ask questions regarding the nature, purpose and risks of the proposed care and those questions have been answered to my satisfaction.

Reason for visit / Procedure requested:

I understand that I may withdraw this consent at any time by providing written notice to the practice, except to the extent that treatment has already been provided based on this consent.

Authorization to Release Medical Information

I authorize the release of my protected health information, including records of care, diagnosis, treatment, and billing information, to the persons or entities indicated below. This authorization includes information related to mental health treatment, communicable diseases, and substance use treatment where applicable unless I specifically mark below to restrict such disclosures.

Release information to (name or relationship):

Limitations and restrictions (if any):

This authorization will expire on:

Assignment of Benefits & Financial Responsibility

I assign benefits payable for services rendered to the practice and authorize direct payment to the practice for such benefits. I understand that I am financially responsible for all charges not covered by insurance, including deductibles, co-payments and services denied by my insurer. I agree to pay collection costs, interest and reasonable attorneys' fees if my account is referred for collection.

Privacy Practices Acknowledgment (HIPAA)

I acknowledge that I have been offered a copy of the practice's Notice of Privacy Practices which describes how my health information may be used and disclosed and how I can obtain access to this information. By signing below I indicate that I have read or been given the opportunity to read the notice and that I understand my rights regarding my protected health information.

Acknowledgment: I acknowledge receipt of the Notice of Privacy Practices

Patient Certifications & Notices

By signing below I certify under penalty of law that the information provided on this form is true and correct to the best of my knowledge. I authorize the practice to communicate with me at the contact information I have provided, and I consent to receiving appointment reminders and health information by voice, text or email unless otherwise indicated in writing.

I understand that I may revoke any authorization provided herein at any time, except to the extent actions have already been taken based upon this authorization. Revocation must be submitted in writing to the practice and will be effective upon receipt.

If signed by legal guardian or personal representative, provide relationship to patient:

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