Healthcare Medical Annex

HEALTHCARE MEDICAL ANNEX

This Medical Annex supplements and forms part of the primary healthcare consent and treatment records maintained by the Provider. It documents additional clinical, insurance and authorization information required to coordinate care, release medical information, and clarify patient preferences. Completion of this Annex constitutes the patient's informed directions and limited authorization as set forth below.

1. Patient Information

Date of Birth:    Gender:

2. Emergency Contact

3. Insurance & Billing Information

4. Medical History & Current Status

Do you use tobacco, alcohol, or recreational drugs?   Tobacco Alcohol Recreational drugs

5. Procedure / Treatment Annex

Risks and Benefits: I acknowledge that no medical or surgical procedure is without risk. The Provider has explained the expected benefits, common and material risks, and reasonable alternatives to the proposed treatment. I understand that certain risks may be unforeseeable and that outcomes cannot be guaranteed.

Right to Withdraw: I understand that I may withdraw consent to non-emergency treatments at any time by providing written notice, except where the Provider has already acted in reliance on prior written consent or where withdrawal would endanger my health.

6. Authorization to Use and Disclose Medical Information (HIPAA Authorization)

I authorize the Provider to use and disclose my protected health information as necessary for the purposes checked below, limited to the period and recipients set forth in this Annex. I understand disclosure is voluntary and that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer protected by federal privacy law.

Purpose(s) of Disclosure (check applicable):
Treatment and care coordination    Billing and payment    Insurance verification/claims    Other (specify below)

Types of Information to be Disclosed (check all that apply):
Medical records, notes and reports    Laboratory and imaging results    Mental health records    Substance use disorder records    HIV/AIDS-related information

Expiration: This authorization will expire on or upon the following event:

Revocation: I understand I may revoke this authorization at any time by delivering a written revocation to the Provider's medical records office. Revocation will not affect disclosures already made in reliance on this authorization prior to receipt of revocation.

7. Special Instructions & Advanced Preferences

Patient acknowledges that information provided herein is accurate to the best of their knowledge and authorizes the Provider and its agents to rely on this Annex in the delivery and coordination of care.

8. Certification & Acknowledgment

By signing below, I certify that I am the patient or the patient's legally authorized representative and that I have read and understand the contents of this Medical Annex. I authorize the uses and disclosures described above and understand that I may receive a copy of this signed Annex upon request. I further certify that the information I have provided is true and complete to the best of my knowledge.

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