Healthcare Human Services Form

HEALTHCARE HUMAN SERVICES FORM

Client Identification

Client Name:

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

Emergency Contact

Insurance / Financial

Medical History

Requested Services / Referral

Requested service types (check all that apply): Case management Care coordination Behavioral health Medical services Dental services Substance use services Housing assistance

Consent for Services and Treatment

I, the undersigned, authorize the provision of healthcare and social services described below. I understand and consent to the assessment, case planning, treatment, coordination of care, and referrals as reasonably necessary for the delivery of services.

Provider / Agency Name:

Purpose of Services:

Anticipated Start Date:

Risks, Benefits and Alternatives: I acknowledge that the proposed services carry benefits, potential risks, and alternatives. These have been explained to me in terms I understand. I have had the opportunity to ask questions and have received satisfactory answers.

Voluntary Consent and Right to Withdraw: I understand that my consent is voluntary and I may withdraw consent at any time by providing written notice to the Provider / Agency, except to the extent that action has already been taken relying on this consent.

Authorization to Release Information

I authorize the disclosure of my protected health information as specified below. I understand that information disclosed pursuant to this authorization may include sensitive categories such as mental health treatment records and substance use treatment records unless I specifically opt out below.

Scope of Information to be Released (check all that apply): Medical records Mental health records Substance use treatment records Billing and payment records Educational records

Expiration: This authorization expires on: . If no date is provided, authorization expires 12 months from the date of signature unless otherwise specified in applicable law.

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

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

Privacy Acknowledgment and Administrative Terms

By signing below I acknowledge receipt of the Provider / Agency's privacy practices and notice of privacy rights. I have been informed of how my protected health information will be used and disclosed in the provision of services and for payment and healthcare operations.

Client Financial Responsibility: I understand that I am responsible for any applicable co-pay, co-insurance, deductibles, or fees for services not covered by insurance and that the Provider / Agency may pursue collection for unpaid balances in accordance with agency policy.

Consent Confirmation: I consent to the provision of services and to the terms set forth in this form.

Client Certification

I certify under penalty of perjury that the information provided on this form is true and complete to the best of my knowledge. I authorize release of any information necessary to process claims and to facilitate care coordination.

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