Healthcare Health Application Form

Healthcare Health Application Form

Complete all applicable sections. The information provided will be used to establish a medical record, determine eligibility for services, coordinate care, and process insurance claims. Providing false or incomplete information may affect treatment or coverage.

Patient Information

Date of birth:    Gender: Male   Female   Other   Prefer not to say

Emergency Contact

Insurance Information

Subscriber date of birth:    Insurance phone:

Medical History

Do you have any of the following conditions? (check all that apply)
Diabetes   Hypertension   Heart disease   Asthma / COPD   Cancer   Immune disorder   None of the above

Do you use tobacco, alcohol, or recreational drugs?   Tobacco   Alcohol   Recreational drugs

Preventive Care / Immunizations

Date of last physical exam:

Consent to Treatment and Authorization

I hereby authorize the physicians, clinicians, and staff of this facility to provide medical evaluation, diagnostic testing, and treatment as may be necessary for my care. I understand that all medical procedures carry potential risks and benefits, and that alternative treatment options may exist. I acknowledge that no guarantee has been made as to the results of any treatment.

I understand I may refuse or withdraw consent to treatment at any time, except where retention of treatment is required by law or to prevent serious harm. I agree to notify the treating provider if I have questions or concerns about recommended tests or procedures.

HIPAA Privacy Acknowledgment

I acknowledge receipt of the Notice of Privacy Practices that describes how my protected health information may be used and disclosed, and my rights regarding that information. By signing below I consent to the use and disclosure of my health information for treatment, payment, and healthcare operations as described in the notice.

I acknowledge that I have received or been offered a copy of the Notice of Privacy Practices.

Authorization to Release Medical Records

I authorize the release of my medical information, including summary of care, diagnostic testing, and treatment records, to the persons or organizations listed below for purposes of coordination of care, referral, or payment. This authorization includes information related to mental health, substance use treatment, and communicable disease, unless I specifically revoke such authorization in writing.

Expiration of authorization:    All medical records

I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance upon it. I further understand that information disclosed pursuant to this authorization may be subject to redisclosure and no longer protected by federal privacy regulations.

Certification

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that it is my responsibility to notify this facility of any changes to my health status, medications, insurance, or contact information.

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