Healthcare MedNet Document

HEALTHCARE MEDNET DOCUMENT

Patient Information

Date of Birth:    Gender: Male Female Other Decline to State

Insurance Information

Medical History

Consent for Treatment and Disclosure

I, the undersigned patient or legal representative, authorize MedNet and its affiliated providers to provide necessary evaluation, diagnostic procedures, and medical treatment as ordered by the attending clinician. I understand that no guarantee has been made as to the results of any treatment.

I acknowledge that the clinician has explained the nature of the proposed treatment or procedure, anticipated benefits, common risks, and reasonable alternatives including the risks of refusing treatment. I have had the opportunity to ask questions and those questions have been answered to my satisfaction.

I have read and understand the risks, benefits, and alternatives described above, and I consent to the proposed care.

HIPAA Authorization and Release of Information

I authorize MedNet to use and disclose my protected health information (PHI) for treatment, payment, and health care operations, including sharing PHI with affiliated providers, referral partners, and third-party payers as necessary. This authorization specifically permits release of records related to substance use, mental health, and communicable disease where applicable and permitted by law.

This authorization will expire on: or upon the occurrence of the following event:

I understand that I may revoke this authorization at any time by giving written notice to MedNet except to the extent that action has already been taken in reliance on this authorization. I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations.

I authorize MedNet to release my PHI as described above.

Assignment of Benefits & Financial Responsibility

I hereby authorize payment of insurance benefits or third-party payments directly to MedNet for services rendered. I assign to MedNet all rights and benefits payable under my insurance policy for services provided. I understand that I am financially responsible for charges not covered or paid by my insurer, including copayments, coinsurance, deductibles, and services deemed non-covered.

I authorize direct payment to MedNet and accept financial responsibility as stated above.

Authorization to leave messages: Voicemail at primary phone    SMS/text messages regarding appointments and billing

Acknowledgements and Certifications

I certify that the information I have provided on this form is true and complete to the best of my knowledge. I understand that falsification or omission of material information may result in denial of services or termination of care.

I understand that I have the right to receive a copy of this signed authorization upon request.

Capacity to consent: Patient has capacity to consent    Signed by legal representative

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