Healthcare Introduction & Release Form

Healthcare Introduction & Release Form

Patient Information

Patient Name:

Date of Birth:    Gender:    SSN (last 4):

Emergency Contact

Insurance Information

Policy/ID Number:    Group Number:

Medical History

Introduction to Care & Consent

I, the undersigned, voluntarily present myself as a patient and request evaluation and treatment. I authorize the clinical staff to provide care, tests, and procedures that are considered advisable and necessary in the judgment of the treating clinicians. I understand that all medical care involves risks and that no guarantee of outcome has been made to me.

I acknowledge that the risks, benefits, and alternatives have been explained to me to the extent reasonably required to make an informed decision. I retain the right to ask questions and to withdraw consent at any time prior to initiation of a procedure or treatment without jeopardizing future care.

Authorization to Release Information & Assignment of Benefits

I authorize the release of my medical information, including diagnosis, treatment, and billing information, to my designated insurer, other healthcare providers, and to the following persons or entities for continuity of care and claims processing. I understand that this information may include information relating to behavioral health, communicable disease, and substance use disorders where applicable.

Assignment of Benefits: I hereby assign all my rights and benefits, and request payment be made directly to the provider for services rendered. I agree to be responsible for charges not covered or paid by my insurer according to the provider's billing practices.

HIPAA Privacy Acknowledgement & Authorized Representatives

I acknowledge receipt of the facility's Notice of Privacy Practices which explains how my protected health information may be used and disclosed, and my rights regarding that information. I understand that I may request restrictions on certain uses and disclosures, and that requests will be considered in accordance with law.

I authorize the provider to disclose my protected health information to the following individuals as needed:

Patient Certification

By signing below I certify that the information I have provided on this form is true and correct to the best of my knowledge. I understand that falsification of information may affect my treatment and insurance coverage. I authorize the release of information and assignment of benefits as indicated above, and I acknowledge my rights under applicable privacy laws.

Sign Now