Healthcare Medical Policies

HEALTHCARE MEDICAL POLICIES

Patient Information

Female Male Other Prefer not to say

Emergency Contact

Insurance Information

Medical History (Brief)

I am currently pregnant I currently use tobacco products

Policy Acknowledgments and Consents

I acknowledge and accept the Financial Policy: I am responsible for payment of services not covered or paid by my insurer, including deductibles, co-payments, co-insurance, and non-covered services. I agree to pay all copays at the time of service and to provide current insurance information.

I authorize assignment of benefits to the provider and authorize release of medical information necessary to process claims. I understand submission of a claim is a convenience and does not release me from financial responsibility for services rendered.

I understand the Cancellation and No-Show Policy: I will provide at least 24 hours' notice to cancel or reschedule. Fees may be charged for missed appointments or late cancellations according to clinic policy.

I acknowledge the Prescription Refill Policy: routine refills require an appointment; allow up to 72 hours for non-urgent refill requests; controlled substances are refilled only with established treatment and at the discretion of the provider.

I consent to routine diagnostic and therapeutic procedures deemed necessary by the treating clinician. I understand that no guarantee has been made as to outcome and I may withdraw consent at any time except where the provider has already relied upon this consent.

I consent to telehealth visits when offered. I understand the limitations and potential risks of remote care and my responsibilities to arrange a private, secure environment and stable connection for such visits.

I authorize release of medical records to other health care providers, my insurance carrier, or individuals as necessary for treatment, payment, or health care operations unless I have submitted a written restriction.

I acknowledge receipt of the Notice of Privacy Practices that describes how my medical information may be used and disclosed and my rights regarding that information.

Authorization Details

By signing below I certify that the information I have provided on this form is true, accurate, and complete to the best of my knowledge. I understand that intentionally providing false information may subject me to denial of benefits, billing adjustments, or legal action. I authorize the provider to obtain clinical and demographic information from other health care entities if necessary for care coordination and treatment.

Sign Now