Healthcare New User Form

HEALTHCARE NEW USER FORM

Please complete all sections. Information provided will be used for medical care, billing, and communication related to treatment. Signing the signature block certifies that the patient (or legal guardian) authorizes treatment and acknowledges the privacy practices and authorizations below.

Patient Information

Patient Name:

Date of Birth: Gender: Male Female Non-binary Prefer not to say

Emergency Contact

Insurance Information

Medical History

Tobacco Use: Never Former Current Alcohol Use: Never Social Regular

Authorizations & Consents

Consent to Treatment: I hereby consent to diagnostic procedures, examinations, and treatments provided by treating clinicians. I understand that all medical procedures have risks and benefits which will be explained prior to treatment when applicable. I acknowledge the right to ask questions and to withdraw consent at any time, except where withdrawal would jeopardize my health or delay emergency care.

Financial Responsibility: I accept financial responsibility for services rendered that are not covered by insurance, and authorize release of information necessary for claims processing. I authorize payment of benefits to the provider for services rendered.

Authorization to Release Medical Records: I authorize release of my medical records to providers, insurers, and other entities involved in my care or payment for care, as necessary to process my claim or coordinate treatment. This authorization expires on:

HIPAA Privacy Acknowledgment

Notice of Privacy Practices: I acknowledge that I have received or been offered the provider's Notice of Privacy Practices describing how my medical information may be used and disclosed and my rights concerning that information. I understand that my protected health information may be used for treatment, payment, healthcare operations, and other purposes permitted by law.

Communication Preferences: I authorize the provider to contact me at the following phone number and email for appointment reminders and care coordination. I understand messages may be left on voicemail or texted.

Acknowledgment of Receipt of Privacy Notice: I acknowledge receipt of the Notice of Privacy Practices

Primary Care & Referrals

Additional Authorizations

Leave Message Authorization: May leave detailed message at primary phone May leave brief message only

Release of Information to Individuals: I authorize disclosure of my protected health information to the following individual(s):

Certification

By signing below, I certify that the information I have provided is true and accurate to the best of my knowledge. I understand that providing false information may affect my care and financial responsibility. I authorize release of medical information to process claims and coordinate care, and I consent to the treatments described where applicable.

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