Healthcare Medical Forms

Patient Intake, Medical History, Consent and HIPAA Authorization

Patient Information

Patient Name:

Date of Birth:    Gender:

Primary Phone:    Email:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy Number:    Group Number:

Subscriber Date of Birth:    Employer:

I authorize release of medical information necessary to process claims and assign benefits to the provider for services rendered. (Initial/Check to authorize)

Medical History

Please indicate current or past diagnoses (check all that apply):

Diabetes    Hypertension    Heart disease    Asthma    Cancer    Mental health disorder    Chronic pain    None of the above

Tobacco use:    Alcohol use:

Consent for Treatment and Financial Responsibility

I authorize the healthcare providers and staff of this practice to provide medical care, examinations, procedures and treatments as deemed necessary for my care. I understand that no specific guarantee of outcome can be made and that all procedures may involve risks including, but not limited to, pain, infection, bleeding, allergic reaction and other complications specific to the procedure performed. I have had the opportunity to ask questions and I understand the risks and benefits of the proposed care.

By checking the box below I consent to the provision of care and accept financial responsibility for services rendered, including co-payments, deductibles and any charges not covered by my insurer. I agree that the provider may release medical information to my insurer as necessary for claims and referral purposes.
I consent to treatment and accept financial responsibility.

Release of Information / Assignment of Benefits

I authorize the release of medical information necessary to process insurance claims and to communicate with other healthcare providers for the purpose of treatment, payment and healthcare operations. I hereby assign to the provider all payments for medical services otherwise payable to me, and authorize payment directly to the provider. I understand that I remain financially responsible for any balances not covered by insurance.

I authorize assignment of benefits and release of information as described above.

HIPAA Authorization and Acknowledgement

I acknowledge receipt of the Notice of Privacy Practices. I authorize the disclosure of my protected health information as necessary to carry out treatment, payment and healthcare operations, and as otherwise described below. This authorization includes release of records related to mental health, substance use disorder treatment, HIV/AIDS status, and genetic testing when applicable.

Person(s) or organization(s) authorized to receive information:

Expiration of authorization (date or event):

I understand that I may revoke this authorization at any time by delivering a written revocation to the practice, except to the extent that action has already been taken in reliance on this authorization. I understand that revocation will not affect any disclosures made prior to receipt of the revocation.

I acknowledge receipt of the Notice of Privacy Practices and authorize release as described above.

Patient Rights and Acknowledgements

I understand that I have the right to ask questions about my care, to refuse treatment (except as required in emergency circumstances), to request restrictions on the use or disclosure of my health information, and to request confidential communications. I certify that the information provided on this form is accurate and complete to the best of my knowledge.

I have read and understand the statements above.

Additional Authorizations

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