Healthcare Medical Village Form

HEALTHCARE MEDICAL VILLAGE FORM

Patient Information

Patient Name:   Date of Birth:

Gender: Male Female Other

Emergency Contact

Insurance Information

Medical History

Consent for Treatment

I, the undersigned, authorize the physicians, nurses, allied health professionals and staff of this Medical Village to provide evaluation, diagnostic testing, medical treatment and procedures as deemed necessary for my care. I understand that medical and surgical procedures involve risks, including but not limited to infection, bleeding, allergic reaction, adverse medication reaction, and unexpected outcomes.

I acknowledge that the nature, purpose, risks and alternatives have been explained to me and that no guarantee has been made concerning the results of any treatment. I understand that I may refuse or withdraw consent at any time, except when care is emergent and delay would endanger my health.

Consent to proceed: I consent to necessary evaluation and treatment

Assignment of Benefits & Financial Responsibility

I hereby assign all medical benefits, if any, to which I am entitled to the provider treating me and authorize said provider to submit claims on my behalf. I authorize payment of medical benefits directly to the provider. I understand that I am financially responsible for all charges not covered by insurance, including deductibles, co-payments, coinsurance, and services deemed not medically necessary by my carrier.

Financial responsibility acknowledgement: I accept financial responsibility for services rendered

Authorization to Release Medical Information

I authorize the release of medical information, including records relating to my care, to my insurance carriers, other healthcare providers for continuity of care, and to persons I designate below. This authorization includes release of information necessary for claims processing and payment.

Expiration of Authorization:   I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it.

HIPAA Privacy Acknowledgment

I acknowledge that I have been offered a copy of the provider's Notice of Privacy Practices describing how my protected health information may be used and disclosed and how I can obtain access to this information. I understand that the provider may use and disclose my health information for treatment, payment, and healthcare operations as described in that notice.

Acknowledgement: I acknowledge receipt of the Notice of Privacy Practices or decline to accept a copy at this time

Patient Certification

I certify that the information I have provided on this form is true and accurate to the best of my knowledge. I understand that falsification or omission of information may affect my care and insurance coverage. I authorize the provider to obtain and release medical information as necessary to furnish care and process claims.

Additional Instructions / Notes

If signed by a personal representative (parent, guardian, or agent), state relationship and authority:

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