Healthcare Medical Corp Document

HEALTHCARE MEDICAL CORP DOCUMENT

Patient Information

Patient Name:    Date of Birth:

Male    Female    Other    Prefer not to say

Insurance Information

Medical History

Consent for Treatment and Release of Information

I, Patient Name: , hereby consent to the provision of medical care, diagnostic testing, medical procedures and/or surgical treatment as deemed necessary by Healthcare Medical Corp and its authorized providers. I authorize performance of the following procedure(s) or treatment(s):

I acknowledge that the nature and purpose of the proposed treatment have been explained to me, including foreseeable risks, complications and benefits. Common risks include, but are not limited to, bleeding, infection, allergic reaction, scarring, anesthesia-related complications, or lack of therapeutic benefit. I understand that no guarantee has been given as to the results of any procedure.

I have been given opportunity to ask questions and these questions have been answered to my satisfaction. I understand that I may withdraw this consent at any time prior to the performance of the procedure, but that withdrawal will not affect any actions already taken by the provider in reliance on this consent.

Financial Responsibility

I authorize assignment of benefits and direct payment to Healthcare Medical Corp for services rendered. I accept financial responsibility for charges not covered or paid by my insurer, including co-payments, deductibles, non-covered services, and any collection or legal costs necessary to obtain payment. I hereby authorize release of medical information as necessary to process insurance claims and coordinate care.

HIPAA Authorization & Privacy Acknowledgment

By signing below I acknowledge receipt of the Notice of Privacy Practices and authorize Healthcare Medical Corp to use and disclose my protected health information for treatment, payment and healthcare operations as permitted by law. I authorize disclosure of information to insurers, other healthcare providers, and persons involved in my care. I understand that my authorization is voluntary and that I may revoke it in writing except to the extent that action has already been taken in reliance upon it.

I acknowledge receipt of the Notice of Privacy Practices and consent to uses and disclosures described above.

Authorization to Release Medical Records

I authorize Healthcare Medical Corp to disclose my protected health information as necessary to other healthcare providers, insurers, family members, legal representatives, or designated third parties for purposes of treatment, payment, coordination of care, and as otherwise permitted by law. This authorization includes release of records related to mental health, substance use, HIV/AIDS status, and communicable diseases unless expressly excluded below.

This authorization will expire on: . If no date is provided, this authorization will expire one year from the date signed, unless a shorter period is required by law.

I understand that I may revoke this authorization at any time by submitting a written revocation to Healthcare Medical Corp, except where action has already been taken in reliance upon this authorization. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy rules.

Patient Declaration

I certify that the information I have provided on this form is true and accurate to the best of my knowledge. By signing below I authorize the performance of the described medical services, accept financial responsibility as described, and authorize release of medical information as necessary. I have read (or had read to me) and understand the statements above and I accept their terms.

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