Healthcare Medmastery Form

Healthcare Medmastery Form

Patient Information

Date of Birth:    Sex / Gender:

Primary Phone:    Secondary Phone:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy / ID Number:    Group Number:

Medical History

Primary Care Physician:    Phone:

Consent for Treatment

I, the undersigned, authorize licensed clinicians and staff affiliated with Medmastery to provide medical evaluation, diagnostic testing, treatment, and routine medical care as deemed necessary. I understand that no procedure or treatment is without risk. I have been informed of the nature and purpose of recommended services, the reasonably foreseeable risks, potential complications, and alternatives, including the option of no treatment.

I acknowledge that I have had the opportunity to ask questions about the procedure and risks and that my questions have been answered in a satisfactory manner. I understand that I may withdraw consent at any time prior to the procedure by notifying the clinician, except where withdrawal would jeopardize my immediate health or safety.

Emergency treatment may be provided if necessary, and I consent to such emergency care if required.

I acknowledge that I have been informed of risks, benefits, and alternatives and agree to proceed with the care described above.

HIPAA Authorization for Release of Protected Health Information

I hereby authorize Medmastery and its clinical staff to use and disclose my protected health information as specified below. I understand that this authorization is voluntary and that treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing this authorization except as allowed by law.

Specific information to be released (check all that apply):

Problem list / diagnoses    Medication list    Laboratory results    Imaging reports

Release entire medical record (including behavioral health and substance use treatment records where applicable)

I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations. I may revoke this authorization at any time by delivering a written revocation to Medmastery, except to the extent that action has already been taken in reliance on this authorization.

Authorization expires on: (if no date provided, expiration is 12 months from signature)

Financial Responsibility & Communications

I accept financial responsibility for services rendered and understand I am responsible for any co-payments, deductibles, or charges not covered by my insurance. I authorize release of information necessary to process claims and consent to communication regarding scheduling, test results, and billing via the contact information provided.

Preferred contact methods (check all that apply):

Phone    SMS / Text    Email    Postal Mail

Patient Rights and Certifications

By signing below, I certify that the information I have provided is true and accurate to the best of my knowledge. I understand my rights to privacy and to receive a copy of this authorization upon request. I understand I may revoke this authorization in writing as described above, except where action has already been taken in reliance upon it.

If signing on behalf of the patient, I certify that I am the patient's legal guardian or authorized representative and that I am authorized to execute this form.

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