Healthcare Health Paperwork

HEALTHCARE HEALTH PAPERWORK

Patient Information

Patient Name:

Date of Birth: Gender: Male Female Other/Prefer not to say

Emergency Contact

Insurance Information

Medical History

Current Medications (include dosage and frequency):

Allergies (medication, food, latex, adhesive, other) — state reaction and severity:

Please indicate current status (check all that apply): Smoker Tobacco use Alcohol use Recreational drug use

Consent for Treatment and Acknowledgments

I authorize healthcare providers, clinicians, technicians and staff of this facility to perform such diagnostic procedures, treatments, and services as may be necessary for my care. I understand that the nature and purpose of the proposed treatment or procedure will be explained to me upon request. I acknowledge that no guarantee has been made as to the results that may be obtained.

Risks and Benefits: I acknowledge that the clinician has provided information about the common and significant risks associated with the proposed treatment and the expected benefits. I understand that alternative treatments (including no treatment) and their risks and benefits have been discussed as applicable. I have had the opportunity to ask questions and to have those questions answered to my satisfaction.

Right to Withdraw: I understand that I may withdraw consent at any time prior to or during treatment, except where withdrawal would create immediate risk to my safety or where treatment is legally authorized without consent.

Special Circumstances: If the patient is a minor or otherwise unable to consent, the undersigned certifies that they are the legal guardian, parent, or authorized representative and have the legal authority to consent on the patient’s behalf.

Authorization to Use and Disclose Health Information (HIPAA Acknowledgment)

I have received or been offered the facility’s Notice of Privacy Practices describing how my health information may be used and disclosed. I authorize the release of my medical information, including diagnosis, treatment summaries, and billing information, to the entities necessary for treatment, payment, and health care operations or as otherwise permitted by law.

Purpose and Scope: This authorization includes release of records necessary for continuity of care, coordination with other providers, insurance and claims processing, and public health reporting where required. This authorization does not permit release of psychotherapy notes unless expressly initialed below.

I authorize the provider to disclose my health information to the following person(s) or organization(s) for the purposes stated below:

Revocation: I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken in reliance on this authorization. To revoke this authorization I must submit a written request to the provider’s records office.

Redisclosure: I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer protected by federal privacy regulations.

Psychotherapy Notes: I authorize release of psychotherapy notes (initial consent required)

Acknowledgments and Certification

By signing below, I certify that the information provided on this form is true and accurate to the best of my knowledge. I authorize the release of medical information and request payment of insurance benefits to the provider where applicable. I understand that I am financially responsible for services not covered by insurance or otherwise agreed to in writing.

I understand that I have the right to request a copy of this authorization and to receive a copy of my medical records as permitted by law. I consent to receive communication related to my care (appointment reminders, test results) by the contact methods I have provided.

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