Healthcare Intake History

HEALTHCARE INTAKE HISTORY

Patient Information

Emergency Contact

Insurance Information

Medical History

Please list current medications, including dose and frequency. Include prescription, over-the-counter, vitamins, and supplements.

Allergies (check all that apply and provide details)

Have you ever been diagnosed with any of the following? Check all that apply.

Current Health Concerns

Preventive Screening Dates

Authorizations, Consents and Acknowledgements

Consent to Treat: I hereby authorize the provider and clinical staff to perform diagnostic procedures and medical treatment as may be deemed necessary or advisable. I understand that no guarantees have been made regarding the results of examination or treatment. I acknowledge that I have the right to ask questions about the proposed care and to refuse any treatment.

Financial Responsibility and Assignment: I accept financial responsibility for services rendered. I authorize the release of any medical information necessary to process claims and request that payment of insurance benefits be made directly to the provider. I understand I am responsible for charges not covered by my insurance.

Authorization for Release of Information: I authorize the release of my protected health information for treatment, payment, and healthcare operations, and for the specific purpose(s) identified below. This authorization includes disclosure of mental health, substance use disorder, HIV testing, and genetic information only if expressly indicated.

HIPAA Notice Acknowledgement: I acknowledge that I have been offered or received a copy of the provider's Notice of Privacy Practices, which describes how my health information may be used and disclosed, my privacy rights, and the provider's legal duties with respect to protected health information.

Minor Consent: If the patient is a minor or is being represented by a legal guardian, the person signing below certifies that they are the parent or legal guardian and have the authority to consent to care and authorizations described in this form.

Patient Certification

I certify that the information provided on this intake form is accurate and complete to the best of my knowledge. I understand that intentionally providing false information may affect my care. I understand that I may revoke authorizations in writing except to the extent that action has already been taken in reliance on this authorization.

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