Healthcare Medical Declaration

HEALTHCARE MEDICAL DECLARATION

I hereby declare that the medical information provided on this form is complete and accurate to the best of my knowledge. I authorize clinicians and administrative staff to use the information supplied for the purpose of my care, treatment, billing, and coordination with other health care providers. I understand that falsification or omission of material medical information may affect treatment and could expose me to risk. I acknowledge my rights to confidentiality and to revoke certain authorizations as stated below.

Patient Information

Patient Full Name:

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

Emergency Contact

Insurance Information

Medical History

Chronic Conditions (check all that apply):

Diabetes Hypertension Heart disease Respiratory disease

Do you have any implanted medical devices (pacemaker, prosthesis, stent, etc.)? Yes No

Declaration of Treatment, Risks, and Consent

Description of Intended Treatment or Evaluation:

I acknowledge that the clinician has explained the nature and purpose of the proposed treatment or evaluation, including commonly known risks and potential benefits. I understand that no guarantee has been made regarding the outcome. I have had the opportunity to ask questions and have received answers satisfactory to me. I understand that I may withdraw consent at any time prior to the initiation of treatment, except where withdrawal may create imminent risk to my health.

Authorization for Release of Information & HIPAA Acknowledgment

I authorize the release of my medical information, including records necessary for billing and coordination of care, to the following parties and to my insurer for payment purposes:

Authorize release to: Spouse Parent Other:

This authorization expires on:

I acknowledge receipt of the facility's Notice of Privacy Practices describing how my health information may be used and disclosed. I understand I may request restrictions and revoke authorizations in writing, except where disclosure has already been made in reliance on this authorization.

Certification

By signing below I certify, under penalty of law, that the information provided on this form is true and complete to the best of my knowledge. I understand that this declaration will be included in my medical record and relied upon by health care providers in making treatment decisions.

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