Healthcare Institute Document

HEALTHCARE INSTITUTE DOCUMENT

Institute Identification

Patient Information

Patient Name:

Date of Birth: Month Day Year

Gender: Female Male Other / Prefer not to disclose

Emergency Contact

Insurance Information

Medical History

Do you use tobacco products? Yes No    Do you use alcohol recreationally? Yes No

Authorizations, Consents, and Acknowledgements

Consent to Medical Treatment — I authorize the healthcare institute and its clinical staff to provide medical care, diagnostic testing and treatment as deemed necessary. I acknowledge that no guarantee has been made as to the results of any examination or treatment. I have been informed of the general risks and benefits of the proposed care and have had the opportunity to ask questions regarding my care.

Patient acknowledges and agrees: Financial Responsibility — I am financially responsible for all charges for services rendered that are not paid by my insurance, including co-payments, deductibles, and services not covered. I authorize the release of medical information necessary to process claims and assign benefits to the treating provider when applicable.

Release of Records — I authorize the institute to release copies of my medical records, billing information, and other protected health information to my insurer, designated agents, and other healthcare providers as necessary for treatment, payment, or healthcare operations.

HIPAA Privacy Acknowledgement — I acknowledge that I have been offered or provided a Notice of Privacy Practices describing how my protected health information may be used and disclosed. I understand my rights to request restrictions and to revoke authorizations in writing, except to the extent the institute has already taken action in reliance on this authorization.

Voluntary Authorization — By checking the box below and signing, I voluntarily authorize the actions and disclosures described above, and I attest that the information I have provided on this form is accurate to the best of my knowledge.

I authorize treatment and related uses and disclosures described above.

I authorize release of medical information for payment and care coordination.

Authorization Period and Revocation

This authorization is effective immediately and shall remain in effect until: Month Day Year .

I understand that I may revoke this authorization at any time by submitting a written revocation to the institute, except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect disclosures made prior to receipt of the revocation.

Additional Consents and Instructions

Certification

By signing below I certify that I am the patient or, if signing on behalf of the patient, I am duly authorized as the patient's personal representative. I attest that I have read and understand the statements above, that my questions have been answered to my satisfaction, and that I consent to the care, uses, and disclosures described in this document.

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