Healthcare Master Generic

HEALTHCARE MASTER GENERIC

This Healthcare Master Generic consolidates patient intake, consent for treatment, authorization to release protected health information, assignment of benefits for billing, and telehealth consent. By signing this form the Patient authorizes the facility and its providers, agents, and representatives to provide evaluation and medical care, to disclose health information as permitted below, and to submit claims for payment in accordance with the terms contained herein.

Patient Information

Date of Birth:    Gender: Male   Female   Other

Emergency Contact

Insurance Information

Subscriber Relationship to Patient: Self   Spouse   Parent   Other:

Medical History

Consent for Treatment

I, the undersigned Patient, hereby consent to and authorize the physicians and clinical staff of this facility to perform such examinations, diagnostic tests, medical treatments and procedures as are considered necessary or advisable for my care. I understand that the nature and purpose of proposed treatment, the common and significant risks and potential benefits, and reasonable alternatives, including the risks and benefits of declining treatment, have been explained to me and I have had the opportunity to ask questions.

I understand that no guarantee or assurance has been made as to the results of treatment. I acknowledge the right to withdraw consent at any time prior to or during treatment, subject to applicable law and the clinician's judgment regarding safe discontinuation of care.

Treatment authorizations (select all that apply):  General evaluation and treatment   Minor procedures/wound care   Anesthesia as indicated

Authorization valid until:

HIPAA Authorization & Privacy

I authorize the facility to use and disclose my protected health information for the purposes of treatment, payment, and healthcare operations, and to disclose health information to persons and entities listed below or as otherwise required or permitted by law. I understand that information disclosed pursuant to this authorization may include sensitive categories, including mental health records, substance use disorder treatment records, and communicable disease information, including HIV status, where applicable, unless I specifically restrict such disclosures below.

Scope of information to be disclosed (check all that apply):  Treatment   Billing/Claims   Laboratory results   Mental health records   Substance use treatment records   HIV/AIDS related information

I understand that I may revoke this authorization at any time by providing a written revocation to the facility's privacy office, except to the extent that action has already been taken in reliance upon this authorization. Unless revoked earlier, this authorization will expire on the date specified above under Authorization valid until.

Assignment of Benefits & Billing Authorization

I hereby assign and authorize payment of medical benefits directly to the treating provider or facility for all services rendered. I authorize release of any medical or other information necessary to process claims and allow photocopies of this authorization to be used in place of the original. I understand I am financially responsible for charges not covered by insurance, including co-payments, deductibles, and services denied by the insurer.

Billing communications: I consent to receiving communications regarding billing and appointments by telephone, voicemail, email, or text message at the contact numbers and addresses provided unless I specifically opt out below.

Opt-out of electronic communications: I do not consent to electronic billing/appointment messages.

Telehealth Consent

I understand that telehealth involves the delivery of healthcare services using interactive audio, video, or other electronic communications. I consent to clinical assessment and treatment via telehealth where offered. I understand there are potential benefits and limitations to telehealth, including the risk of technical failure or breaches of privacy, and that I may decline or discontinue telehealth at any time.

Consent to telehealth: I consent to receive telehealth services.

Minor Patient / Guardian

If the patient is a minor or otherwise legally incompetent to consent, the undersigned certifies that they are the parent, legal guardian, or authorized representative and have authority to consent on behalf of the patient. Relationship to patient:

Patient Acknowledgment

By signing below I acknowledge that I have read and understand this Healthcare Master Generic form, that my questions have been answered to my satisfaction, and that I consent to the terms and authorizations contained herein. I certify that the information provided on this form is true and complete to the best of my knowledge.

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