Healthcare HRSA Document

HRSA PATIENT INTAKE & AUTHORIZATION

Clinic/Program Name:    Program ID (if applicable):

Patient Information

Date of Birth:    Gender: Female Male Non-binary Decline to State

Emergency Contact

Insurance & Financial

I authorize clinic staff to obtain and verify insurance benefits and to bill third-party payors on my behalf: Yes No

Medical History

Program Eligibility Information

Household Size:    Annual Household Income: $

I certify that the information provided for program eligibility and billing is true and complete to the best of my knowledge. I understand that providing false information may affect eligibility for services and result in required repayment of funds.

Consent for Treatment & Authorization to Release Information

I authorize the provision of medically necessary health care, diagnostic procedures, and treatment by authorized clinic providers. I understand the nature, purpose, expected benefits, and material risks of proposed care. Procedure/Service Description:

Risks and Benefits: I have been informed of the reasonably foreseeable risks, benefits, and alternatives to the treatment or procedure described above. I have had an opportunity to ask questions and understand that no guarantee has been made concerning the results of treatment. I have the right to withdraw consent at any time prior to the procedure.

Authorization to Release Protected Health Information (PHI): I authorize release of my PHI to clinic staff, program administrators, and funders for purposes of treatment, payment, care coordination, program reporting, and quality assurance. This authorization includes medical records, eligibility documentation, and billing information.

Release To (name or entity):

Purpose of Disclosure:

Expiration of Authorization: This authorization will expire on unless earlier revoked in writing.

Right to Revoke: I understand that I may revoke this authorization at any time by providing a written notice to the clinic, except to the extent that action has already been taken in reliance on this authorization.

Acknowledgments & Certifications

Confidentiality Notice: Clinic staff will treat my records and personal information as confidential as required by law. Disclosures permitted by my signature include those necessary for treatment, payment, program administration, and required reporting to funding entities. Any further disclosure will require my separate written authorization unless otherwise permitted or required by law.

By signing below I certify that I have read and understand the information on this form, that I am the patient or am authorized to sign for the patient, and that the information provided is true, accurate, and complete. I authorize clinic staff to provide care, to verify benefits, and to release information as described above.

Special Notices

Non-Discrimination: Services are provided without regard to race, color, national origin, sex, age, religion, disability, or source of payment. If assistance is needed to complete this form due to language or communication barriers, please request interpreter services.

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