Healthcare Health Promotion Document

HEALTHCARE HEALTH PROMOTION DOCUMENT

Patient Information

Patient Name:

Date of Birth:    Gender: Female Male Other

Emergency Contact

Insurance Information

Medical History (Relevant)

Health Promotion Program Details

Program Title:

Proposed Start Date:    Target Completion Date:

Goals, Objectives, and Follow-up

Consent and Authorizations

By signing below I acknowledge that I have received a clear explanation of the health promotion program, the interventions proposed, and the expected benefits. I understand that participation is voluntary and that I may withdraw at any time without penalty to my ongoing medical care.

I consent to participate in the health promotion program and agree to follow the mutually agreed care plan.

I consent to receive educational materials, reminders, and program-related communications by phone, text, or email as indicated below:
Preferred contact method: Phone Text Email

I authorize the release and exchange of program-relevant information to coordinate care with my primary care provider, listed specialists, and my insurer where necessary for program delivery and billing.

Privacy, Data Use and Liability

I acknowledge that information created, used or disclosed in connection with this program is subject to applicable privacy protections. This authorization does not alter my rights under applicable privacy laws, including the right to revoke this authorization in writing, except to the extent that the program has already acted in reliance on it.

I understand that reasonable efforts will be made to protect my personal health information. I release the program and its staff from liability for the inadvertent disclosure of information except for disclosures that result from gross negligence or willful misconduct.

Risks, Benefits, and Right to Withdraw

Known benefits include improved health knowledge, behavior change, and better chronic disease management. Known risks are minimal but may include transient discomfort, exercise-related soreness, or inadvertent disclosure of health information. I have had an opportunity to discuss risks and benefits and have had my questions answered.

I understand that participation is voluntary. I may withdraw my consent at any time by notifying program staff in writing. Withdrawal will not affect my entitlement to future medical care or benefits to which I am otherwise entitled.

Referrals and Additional Resources

Acknowledgment

By signing below I certify that the information I have provided on this form is true and complete to the best of my knowledge. I acknowledge that I have received an explanation of the program and consent to participate under the terms set forth above.

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