Healthcare GSA Form

HEALTHCARE GSA FORM

Patient Information

Patient Name:

Date of Birth: Month Day Year

Male Female Other / Prefer not to say

Emergency Contact

Insurance Information

Medical History

Primary Care Physician:

Do you have an implanted device (e.g., pacemaker)? Yes No

Consent, Authorization, and Administrative Terms

I hereby authorize clinicians and authorized staff to provide evaluation and medically necessary treatment. I consent to procedures, diagnostics, and care determined by clinical staff to be indicated. I understand that no guarantee has been made to me regarding the results of any examination or treatment.

Authorization for Release of Information and Assignment of Benefits: I authorize the release of medical and billing information necessary to process claims, coordinate care, or as required for payment and administrative purposes. I assign benefits payable for services to the provider and request payment be made directly to the provider when applicable. This authorization includes mental health, substance use disorder, and HIV-related information unless specifically excluded in writing below.

I understand that I may revoke this authorization at any time by delivering a written notice to the provider, except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect disclosures made prior to receipt of revocation.

Authorization Expiration: This authorization will expire on unless an earlier date or event is specified here:

Financial Responsibility and Billing: I accept financial responsibility for services not covered or paid by my insurance, including co-payments, deductibles, and non-covered services. I authorize release of information required for billing and appeals. I understand that collection actions may be taken for unpaid balances consistent with provider policy.

HIPAA Privacy Acknowledgment

By signing below I acknowledge receipt of the provider's Notice of Privacy Practices and understand my rights regarding the use and disclosure of my protected health information. I understand that the provider may use my information for treatment, payment, and healthcare operations and that requests for restrictions or confidential communications must be submitted in writing.

Patient Preferences for Contact and Release of Information:

May we leave appointment reminders at the phone number provided? Yes No

May we release medical information to the emergency contact listed above? Yes No

Special Accommodations / Instructions

Administrative Use Only

Service Location:

Account/Record Number:

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