Healthcare MWC Service Form

HEALTHCARE MWC SERVICE FORM

Patient Information

Please provide the patient's full legal name and identifying information.

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

Emergency Contact

Insurance Information

Insurance coverage is collected for billing purposes. Provide the subscriber information below.

Service Details

This Mobile Wellness Clinic (MWC) provides limited on-site clinical services. Complete the details of the service encounter.

Date of Service:    Location:

Primary care consultation   Vaccination   Lab draw   Screening (e.g., BP, glucose)   Other (see description below)

Presenting Condition & Medical History

Are you currently pregnant?   Yes   No

Consent to Treatment and Acknowledgements

I authorize Mobile Wellness Clinic personnel to provide the clinical services selected above. I understand that services provided within the MWC setting are limited and that the clinician will explain the nature and purpose of the proposed services, expected benefits, common risks, and reasonable alternatives prior to treatment. I understand that risks can include, but are not limited to, allergic reaction, fainting, bleeding, infection, or incomplete resolution of the condition. I have had the opportunity to ask questions and those questions have been answered to my satisfaction.

I understand that I may withdraw consent at any time prior to or during treatment, except in emergency situations where withdrawal would endanger my health. Withdrawal of consent will not affect the right to receive future services.

By checking the box below I acknowledge that I have read and understand the above consent statements and authorize the provision of the selected services.

I consent to the proposed MWC services and related care.

HIPAA & Release of Information

I acknowledge that I have received or been offered the facility's Notice of Privacy Practices describing how my protected health information (PHI) is used and disclosed. I authorize release of PHI, including records of treatment, billing, laboratory results, and immunizations, to my insurance carrier and to other healthcare providers as necessary to coordinate care. I understand that PHI will be disclosed only as necessary for treatment, payment, and healthcare operations unless I provide a separate written authorization.

I authorize the Mobile Wellness Clinic to communicate with me at the address and telephone numbers provided regarding appointments, reminders, billing, and clinical information. Messages left on voicemail or with household members may include identification of the clinic and brief clinical or billing information.

I acknowledge receipt of the Notice of Privacy Practices and authorize disclosures as described above.

Financial Responsibility

I understand that I am financially responsible for charges not covered by insurance, including co-payments, deductibles, co-insurance, and services denied as non-covered. I authorize payment of benefits to the provider for services rendered and assign benefits to the Mobile Wellness Clinic to the extent permitted. I authorize the release of any medical or other information necessary to process claims.

I agree to the financial responsibility terms above.

Additional Authorizations

I authorize provision of care at the location indicated above and understand that the MWC environment may be different from a traditional clinic setting. I permit clinical staff to take photographs or videos for treatment documentation and clinical record keeping unless I indicate otherwise below.

I consent to photographs/videos for clinical documentation.   I do not consent to photographs/videos.

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 knowingly providing false information may affect my care and insurance coverage. I have read and understand this form and have had the opportunity to ask questions.

I certify that the above information is accurate and complete.

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