Healthcare Initial Agreement

HEALTHCARE INITIAL AGREEMENT

Patient Information

Patient Name:

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

Insurance Information

Medical History

Consent for Treatment

I, the undersigned, authorize licensed clinical staff of this practice to provide routine diagnostic and therapeutic services as deemed medically necessary. I understand that all treatments and procedures involve some degree of risk. Significant risks, if any, will be explained prior to the procedure when reasonably possible.

I acknowledge that no guarantees have been made to me regarding the outcome of any treatment. I retain the right to withdraw consent at any time by providing written notice to the provider, except in emergencies where immediate care is necessary to prevent serious harm.

Consent to general treatment: I consent to evaluation and treatment by the provider.

HIPAA / Privacy Authorization

I acknowledge that I have been offered a copy of the Notice of Privacy Practices describing how my protected health information may be used and disclosed. I authorize the release of my protected health information to third parties for purposes of treatment, payment, and healthcare operations as necessary.

Specific release for records to/from other providers and insurers: I authorize release of records as necessary for continuity of care and billing.

Financial Responsibility

I agree to be responsible for payment of charges for services rendered that are not covered by my insurance. This includes deductibles, co-payments, co-insurance, and services denied by my insurer. I authorize direct payment of benefits to the provider when applicable.

I understand that if my account is referred for collection, I may be responsible for collection costs and reasonable attorney fees to the extent allowed by law.

Assignment of benefits: I assign insurance benefits to the provider where applicable.

Appointment and Cancellation Policy

Appointments cancelled with less than 24 hours notice may incur a late cancellation fee. Failure to attend a scheduled appointment without notice may be considered a no-show and be subject to a no-show fee. Repeated missed appointments may result in termination of the patient-provider relationship.

Acknowledgments and Certifications

By signing below I certify that the information provided on this form is true, complete, and accurate to the best of my knowledge. I understand that intentionally providing false information may be grounds for refusal of service.

I understand that I may request a copy of any records I sign to authorize for release. I also understand policies regarding privacy and financial responsibility as set forth above.

Acknowledgment of receipt and consent: I acknowledge that I have read, understand, and agree to the terms and statements contained in this Healthcare Initial Agreement.

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