Healthcare Intro Form

HEALTHCARE INTRO FORM

Patient Information

Patient Name:

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

Emergency Contact

Insurance Information

Medical History

Do you use tobacco products? Yes No    Do you consume alcohol regularly? Yes No

Consent to Treatment

I, the undersigned, authorize authorized healthcare providers and support staff to provide evaluation, diagnostic tests, medical treatment and procedures as deemed necessary in the course of my care. I have been informed that treatment may include medical examinations, laboratory testing, imaging, administration of medications, and minor procedures.

Risks and Benefits: I understand that all medical interventions carry potential benefits and risks, including but not limited to allergic reaction, infection, bleeding, and unforeseen complications. The provider has discussed anticipated benefits and material risks with me and answered my questions to my satisfaction.

Withdrawal of Consent: I understand that I may refuse or withdraw consent to treatment at any time, except where such refusal would jeopardize my safety or delay emergency care. Withdrawal of consent will be documented in my medical record.

Consent for Routine Tests: I authorize performance of routine diagnostic tests and release of results to treating clinicians for continuity of care.

HIPAA Privacy Acknowledgment & Authorization to Disclose

Acknowledgment: I acknowledge that I have been provided an opportunity to receive the practice's Notice of Privacy Practices describing how my protected health information may be used and disclosed, and my rights under applicable privacy laws.

Authorization to Disclose: I authorize the release of my health information, including but not limited to diagnosis, treatment records, billing records, and laboratory results, to the following persons or entities for purposes of treatment, payment, and healthcare operations:

Expiration: This authorization expires on:    or upon the following event:

Revocation: 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 on this authorization.

Financial Responsibility & Assignment

Assignment of Benefits: I authorize payment of benefits directly to the treating provider for services rendered. I understand that I am financially responsible for charges not covered by my insurance, including co-payments, deductibles and non-covered services.

Billing: I agree to the practice's standard billing procedures. If my account is referred for collection, I agree to pay associated collection costs as permitted by law.

Additional Authorizations

Telephone and Electronic Communications: I consent to receive appointment reminders, clinical messages and billing communications via telephone, voicemail, text message, and email at the numbers and addresses I have provided. I understand these communications may not be encrypted.

Patient Certification

By signing below I certify under penalty of perjury that the information provided on this form is true and complete to the best of my knowledge. I consent to the use and disclosure of my protected health information as described above and consent to treatment by the providers at this practice. I understand that I may request a copy of this form.

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