Healthcare Health Assurance Document

HEALTHCARE HEALTH ASSURANCE DOCUMENT

Clinic Name:    Patient Name:    Document Date:

1. Patient Information

2. Insurance Information

3. Medical History

4. Health Assurance, Consent, and Authorizations

Accuracy Assurance: I certify that the medical and insurance information I have provided on this form is true, complete, and correct to the best of my knowledge. I understand that falsification or omission of material information may affect the quality of care and may be grounds for denial of services or billing adjustments.

Consent to Treatment: I authorize the health care providers and their delegates to perform diagnostic procedures and treatment as deemed medically necessary. I understand that no guarantee has been made to me regarding the outcome or results of treatment. By checking the box I give informed consent for routine and emergency care. I consent to treatment

Release of Information: I authorize the release of my health information, including medical records and billing information, to my insurance company, health care providers, and their authorized agents for purposes of treatment, payment, and health care operations consistent with applicable privacy laws. This authorization includes diagnosis, treatment records, and billing records. I authorize release of records

Assignment of Benefits: I assign benefits and authorize payment of medical benefits to the provider for services furnished. I understand I remain financially responsible for charges not covered by insurance, including co-payments, deductibles, co-insurance, and any non-covered services. By checking below I authorize direct payment to the provider. Assign benefits to provider

HIPAA Acknowledgment: I acknowledge receipt of the provider's privacy practices and understand that protected health information will be used and disclosed in accordance with those practices and applicable laws. I understand my rights to request restrictions and to revoke authorizations in writing, except to the extent that action has already been taken in reliance upon this authorization. I acknowledge privacy practices

Right to Revoke: I understand that I may revoke this authorization at any time by notifying the provider in writing, except where actions have already been taken in reliance on this authorization. This authorization will remain valid until the expiration date indicated below or until revoked in writing.

5. Financial Responsibility and Billing

I accept financial responsibility for services rendered that are not paid by my insurance carrier. I understand that I will be billed for balances, may be responsible for collection costs, and that the provider may release information necessary to obtain payment. I agree to notify the provider of any changes in my insurance coverage.

6. Patient Certifications

By signing below I certify that I have read and understand the statements above, that I have had an opportunity to ask questions regarding my care, and that I authorize the actions and disclosures described in this document. I acknowledge that a photocopy or electronic copy of this authorization is as valid as the original.

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