Healthcare Introduction & Consent Form

HEALTHCARE INTRODUCTION & CONSENT FORM

Facility Name:

PATIENT INFORMATION

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

EMERGENCY CONTACT

INSURANCE INFORMATION

MEDICAL HISTORY

Primary Care Provider:    Phone:

CONSENT FOR TREATMENT

I, the undersigned, consent to evaluation, diagnostic testing, medical and/or surgical treatment as recommended by the licensed practitioners of the facility. I understand that the nature of treatment, anticipated benefits, common risks, and reasonable alternatives have been explained to me and I have had an opportunity to ask questions.

I acknowledge that no guarantees have been made regarding the results of treatment. Risks may include, but are not limited to, infection, bleeding, allergic reaction, unexpected outcomes, and complications inherent to procedures and medications. I consent to such diagnostic and therapeutic procedures as deemed necessary in the professional judgment of the treating practitioners.

I authorize qualified personnel to perform routine procedures, administer medications, and provide emergency medical care should it become necessary. I understand that I may refuse or withdraw consent at any time, except when withdrawal would jeopardize my health or when treatment has already been rendered based on my prior consent.

Consent for treatment: I consent to evaluation and treatment as described above.

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION & ASSIGNMENT

I authorize the facility to use and disclose my protected health information as needed for treatment, payment, and healthcare operations. I authorize release of medical information to insurers, other healthcare providers, and entities involved in my care for the purposes of payment and continuity of care.

I hereby assign to the facility all payments for medical benefits payable to me for services rendered. I understand that I remain financially responsible for charges not covered by insurance, including co-payments, deductibles, and services denied by my insurer.

Authorization to release records: I authorize the release of medical records as described above.

This authorization expires on:    I understand I may revoke this authorization at any time by submitting a written request, except to the extent action has already been taken in reliance on this authorization.

PRIVACY & NOTICE ACKNOWLEDGMENT

I acknowledge that I have been offered or received a copy of the facility's Notice of Privacy Practices describing how my protected health information may be used and disclosed, and my rights regarding that information.

Acknowledgment of privacy notice: I acknowledge I have been offered or received the Notice of Privacy Practices.

COMMUNICATION PREFERENCES

I authorize the facility to leave messages regarding appointments and treatment at the following:

Home phone    Mobile phone    Email

If other persons may receive protected health information on my behalf, list names and relationship below:

FINANCIAL AGREEMENT

I agree to be financially responsible for services rendered and understand that payment is due at the time of service unless other arrangements have been made in writing. I authorize release of information necessary to process insurance claims and authorize payment of benefits to the provider.

Financial responsibility agreement: I agree to the terms above.

ADDITIONAL INFORMATION

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