Healthcare Onboarding Document

HEALTHCARE ONBOARDING DOCUMENT

Patient Information

Date of Birth:    Gender (select one):   Male Female Other/Prefer not to say

Emergency Contact

Insurance Information

Medical History

Do you have any implantable devices or pacemakers?   Yes No

Consents and Authorizations

Consent to Treatment: I hereby authorize licensed healthcare providers and their designees to provide examination, diagnostic procedures and medical treatment as deemed necessary for my care. I understand that no guarantee has been made as to the results of any treatment.

Release and Exchange of Information: I authorize release of medical information including records, test results and billing information to other health care providers, my insurance carrier, and entities involved in my care for the purposes of treatment, payment and health care operations. This authorization remains in effect until revoked in writing.

Assignment of Benefits: I assign to the treating facility and/or provider any insurance or third-party benefits payable for services rendered to me. I understand that I am financially responsible for charges not covered by insurance or other payers.

Financial Responsibility: I acknowledge responsibility for payment of co-payments, deductibles, non-covered services, and any services deemed not medically necessary. I agree to provide accurate insurance information and to notify the practice promptly of changes.

Voluntary Consent and Right to Withdraw: I understand that my consent is voluntary. I may revoke this authorization at any time by providing a written notice, except to the extent that action has already been taken in reliance on this authorization.

Minors and Guardianship: If the patient is a minor or legally incapable of consenting, the undersigned certifies that they are the parent or legal guardian and have authority to sign on behalf of the patient.

HIPAA / Privacy Acknowledgement

Acknowledgement of Privacy Practices: I acknowledge receipt of the facility's Notice of Privacy Practices that describes how my medical information may be used and disclosed. I understand that I may request restrictions on certain uses and disclosures by submitting a written request.

Confidential Communications: I request that communications regarding my care be made to the following telephone number(s) or address (if different from above):

Authorization Expiration

This authorization expires on:    If no date entered, authorization will remain in effect until revoked in writing.

Certifications

I certify that the information provided on this document is true and complete to the best of my knowledge. I understand that falsification or omission of material facts may affect my ability to receive benefits or services.

By signing below I give consent for treatment, authorize release of information as stated above, accept financial responsibility, and acknowledge receipt of privacy information.

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