Healthcare Initiation Form

HEALTHCARE INITIATION FORM

Patient Information

Date of Birth:    Gender:

Primary Phone:    Secondary Phone:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy Number:    Group Number:

Subscriber Date of Birth:    Insurance Phone:

Medical History

Do you use tobacco products? Yes No

Consent for Treatment and Authorizations

By signing below, I authorize the facility and its healthcare providers to provide medical evaluation, diagnostic procedures and treatment as deemed necessary for the patient's care. I acknowledge that no guarantees have been made to me regarding the results of the treatment. I understand that I have the right to ask questions, to receive information about the proposed services, and to withdraw consent at any time except to the extent that action has already been taken in reliance on this consent.

Assignment of Benefits and Financial Responsibility: I hereby assign to the provider all insurance or third-party benefits payable to me for services rendered. I authorize the release of information necessary to secure payment. I accept financial responsibility for charges not paid by insurance, including co-payments, deductibles, and services excluded by my plan.

I accept financial responsibility as stated above.

Authorization to Release Medical Information

I authorize the release of my protected health information, including diagnosis, treatment records and billing information, to the persons or entities listed below for continuity of care, payment, and healthcare operations. Information disclosed may include mental health, substance use, HIV/AIDS and communicable disease information only where permitted by law or where I have indicated consent.

Purpose of Disclosure:

I authorize release of all medical records pertinent to this request.
I authorize release of specific records only (indicate below).

HIPAA Privacy Acknowledgment

I acknowledge that I have been provided with the practice's Notice of Privacy Practices that describes how my medical information may be used and disclosed and how I can obtain access to this information. I understand that I may request restrictions on certain uses and disclosures and that I may revoke this authorization in writing at any time, except to the extent action has been taken in reliance on it.

I acknowledge receipt of the Notice of Privacy Practices.

Authorization Expiration and Revocation

This authorization will expire on: . I understand I may revoke this authorization at any time by providing a written revocation to the facility, except to the extent the facility has already acted in reliance on this authorization.

Certification and Patient Statement

I certify that the information I have provided on this form is true and correct to the best of my knowledge. I understand that providing false information may subject me to civil or criminal penalties in accordance with applicable law. I authorize the use of a facsimile or electronic copy of this form as if it were an original.

Preferred method for appointment reminders and communications:
Phone Call Text Message Email

Sign Now