Healthcare Health Program Form

Healthcare Health Program Form

Program Enrollment

Program Name:    Program Start Date:

Patient Information

Date of Birth:    Gender: Male Female Other

Phone:    Email:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy Number:    Group Number:

Medical History & Current Status

No known allergies Has allergies — specify below

Diabetes Hypertension Asthma / COPD Heart disease

Primary Care Provider:    Phone:

Program Participation Consent & Acknowledgments

I consent to participate in the health program named above. I understand that the program may include health assessments, supervised exercise, education, counseling, telehealth contacts, and coordination with other health care providers. I acknowledge that program staff have explained the nature, purpose, potential benefits and reasonably foreseeable risks of participation.

Risks include, but are not limited to, exacerbation of medical conditions, fainting, musculoskeletal injury, allergic reaction to treatments, or emotional distress. I affirm that I have disclosed all known medical conditions and medications to program staff and will notify staff promptly of any changes.

I understand that participation is voluntary and I may withdraw at any time. Withdrawal will not affect my right to receive future care. I authorize program staff to provide or arrange emergency medical care if, in their judgment, such care is necessary.

I consent to telehealth services when offered. I understand telehealth has limitations including potential privacy risks and technology failures. I authorize program staff to communicate with me via phone, text, or secure electronic means as part of care coordination.

Release of Information & HIPAA Authorization

I authorize release of my protected health information to program staff, affiliated providers and my insurance carrier for purposes of treatment, payment, and health care operations related to program participation. Information released may include medical history, test results, and progress notes as reasonably necessary.

I understand I may revoke this authorization in writing at any time, except to the extent that the program has acted in reliance on the authorization. This authorization expires on the date specified below or upon termination of program services, whichever occurs first.

Authorization Expiration Date:

I acknowledge receipt of the program's Notice of Privacy Practices and understand my rights regarding my health information.
I acknowledge receipt of the Notice of Privacy Practices

Financial Responsibility & Billing

I agree to be financially responsible for services rendered that are not paid by insurance. I authorize the program to bill my insurance and to release any information necessary to process claims. I understand I may receive separate statements for services or copay obligations.

Additional Information

Certification & Signature

By signing below I certify that the information I have provided is true and accurate to the best of my knowledge. I understand that providing false information may affect my eligibility for program services. I agree to notify program staff of any material changes in my health status.

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