Healthcare NP Paperwork

NURSE PRACTITIONER PATIENT INTAKE & CONSENT

Patient Information

Date of Birth:     Gender:

Phone:     Email:

Relationship:     Phone:

Insurance Information

Policy / ID #:     Group #:

Medical History

Do you smoke? Yes No     Do you drink alcohol? Yes No

For females: Are you currently pregnant? Yes No

Primary Care & Referrals

Consent for Treatment by Nurse Practitioner

I, the undersigned patient, authorize the Nurse Practitioner (NP) and the supervised clinical team to provide evaluation, diagnostic testing, medical treatment, and prescribed medications as deemed necessary by the NP within the scope of practice. I understand that the NP may perform minor procedures, order laboratory tests and imaging, and refer to other providers when appropriate.

I understand that all medical procedures carry risks which may include, but are not limited to, infection, bleeding, allergic reaction, incomplete resolution of the condition, or adverse reaction to medications. The NP has explained the nature and purpose of the proposed care and the reasonable alternatives, including no treatment. I have had the opportunity to ask questions and receive satisfactory answers.

I acknowledge that I have the right to refuse or withdraw consent at any time, except when doing so would create a medical emergency or otherwise jeopardize my safety. Withdrawal of consent will be documented and discussed with the NP.

By signing below, I consent to treatment by the Nurse Practitioner and authorize the NP to administer treatment as indicated.

Privacy, HIPAA Acknowledgment & Authorization

I acknowledge that I have received or been offered a copy of the practice's Notice of Privacy Practices and that my health information may be used and disclosed for treatment, payment, and health care operations as described in that notice. I understand that I may request restrictions and that requests will be considered but not guaranteed.

I authorize release of my medical information to insurance carriers and other entities as needed to process claims and payment. I authorize the NP to communicate protected health information to the following persons (optional):

Authorization expiration (if any):

Financial Responsibility & Assignment of Benefits

I assign benefits to the practice to apply insurance payments directly to any balance owed. I understand I am financially responsible for charges not covered by insurance, including co-payments, deductibles, non-covered services, and collection fees. I authorize the release of medical information necessary to process claims and authorize payment of benefits to the treating provider.

If the practice determines that services rendered are not covered or are denied by my insurer, I agree to be responsible for payment in a timely manner. Billing inquiries should be directed to the practice billing office.

Telehealth / Remote Visit Acknowledgment (if applicable)

I consent to the use of telehealth technology for portions of my care when offered. I understand telehealth may include audio, video, or other electronic communications. I understand limitations of telehealth visits, including technical failures, and that not all services are appropriate for remote delivery.

Acknowledgments and Signatures

I certify that the information I have provided is true and complete 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 the consents, authorizations, and financial obligations contained in this document.

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