Healthcare Intake Forms

HEALTHCARE INTAKE FORM

Patient Information

Patient Name:    Date of Birth:    Gender: Male Female Other

Emergency Contact

Insurance Information

Medical History

Do you have any of the following chronic conditions? (check all that apply)
Diabetes Hypertension Heart disease Asthma/COPD None of the above

Tobacco use: Never Current Former

Alcohol use: Never Social Regular

Consent for Treatment • Financial Responsibility • Authorization

I, the undersigned, hereby consent to any diagnostic procedures, examinations, medications and medical treatment, including routine nursing procedures, that may be performed by the provider and clinical staff as deemed necessary. I understand that the practice will explain the nature, purpose and expected benefits of recommended procedures. I acknowledge that no guarantees have been made regarding results.

I authorize the release of information necessary to process claims to my insurer and authorize payment of medical benefits to the provider. I accept financial responsibility for charges not covered or payable by my insurer, including co-payments, deductibles and non-covered services. I understand that I may be billed for missed appointment fees in accordance with clinic policy.

I authorize the provider to obtain, release and exchange my protected health information for the purposes of treatment, payment and healthcare operations as necessary to provide care. This authorization includes release of records to other healthcare providers, facilities, and payers for continuity of care and claim adjudication.

I understand that I may revoke this authorization at any time by providing written notice, except to the extent that action has already been taken in reliance upon this authorization. This authorization will remain in effect until the specified expiration date or until revoked in writing.

HIPAA Privacy Acknowledgment

I acknowledge that I have been given the opportunity to review the health care provider's Notice of Privacy Practices describing how my protected health information may be used and disclosed and how I can obtain access to this information. By signing below I consent to the uses and disclosures of protected health information for treatment, payment and healthcare operations as described in that Notice.

Communications: I consent to appointment reminders and health information via phone, voicemail, text, or email at the contact information provided. I understand that electronic communications may not be secure and that the provider will take reasonable steps to protect my privacy.

Acknowledgment of Rights: I have the right to request restrictions on certain uses and disclosures of my health information and to request confidential communications. Requests must be submitted in writing.

Release of Records

I authorize the release of medical records as necessary for treatment, referral, payment, and legal purposes. I understand that sensitive information such as mental health records, substance use treatment records, HIV/AIDS-related information, and genetic testing information will only be released with my explicit written consent unless otherwise permitted by law.

Patient Certification

By signing below I certify that the information provided on this form is accurate and complete to the best of my knowledge. I understand that providing false or incomplete information may affect my care. I authorize treatment and agree to the terms stated above regarding financial responsibility and release of information.

If signing as an authorized representative, I certify that I am authorized to make healthcare decisions on behalf of the patient and that I will provide documentation of such authority upon request.

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