Healthcare Membership Record

Healthcare Membership Record

Membership Details

Membership ID:

Individual    Family    Corporate

Enrollment Date:     Effective Date:     Termination Date:

Patient Information

Emergency Contact

Insurance Information

Medical History & Current Status

Patient is a current smoker     Patient reports regular alcohol use

Consent, Authorization & Acknowledgments

Membership Terms: By signing this record, the patient certifies that the information provided is true and complete to the best of their knowledge. Membership is subject to the organization's eligibility criteria and payment of required fees. The organization reserves the right to modify benefits or terminate membership in accordance with published policies; the member will be notified in writing of any material changes.

Financial Responsibility: The member acknowledges responsibility for copayments, deductibles, coinsurance, and charges not covered by insurance. The organization may bill the patient directly for services not paid by the insurer. The patient authorizes assignment of benefits to the provider for payment of services rendered.

Authorization to Release Medical Information: I authorize the release of medical and billing information necessary to process claims to insurers, other health care providers, and third-party payers as needed for treatment, payment, and health care operations. This authorization includes summary and narrative records, test results, and correspondence.

HIPAA Acknowledgment: I acknowledge that I have received or been offered the organization’s Notice of Privacy Practices regarding protected health information. I understand that my health information will be used for treatment, payment, and health care operations and that I have rights as specified in the Notice.

Emergency Treatment Consent: In the event of an emergency, I authorize necessary medical care pending consent from my authorized representative. The organization and its agents are not liable for acts performed in good faith under emergent conditions.

I authorize release of my records as described above.

I authorize billing to my insurance carrier and assignment of benefits to the provider.

I acknowledge receipt of the privacy practices notice and understand my rights regarding protected health information.

Revocation: I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken in reliance thereon. Revocation does not affect disclosures made prior to receipt of the revocation.

Acknowledgment

By signing below, I certify that I have read and understand the terms of this Healthcare Membership Record, that the information provided is accurate, and that I consent to the uses and disclosures described above to the extent necessary for treatment, payment, and health care operations.

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