Healthcare Onboarding Form

HEALTHCARE ONBOARDING FORM

Patient Information

Patient Name:

Date of Birth:    Gender: Female Male Other/Prefer not to say

Emergency Contact & Primary Care

Insurance Information

Medical History

Current medications (include dose and frequency):

Allergies (medication, food, environmental) and reaction:

Prior surgeries / hospitalizations (include year and reason):

Chronic conditions / ongoing diagnoses:

Do you use tobacco? Yes No    Are you pregnant or trying to become pregnant? Yes No

Consent to Treatment & Administrative Authorizations

By signing below, I authorize the healthcare providers and staff of the practice to provide medical care and treatment as may be deemed necessary for my health. I understand that all procedures, tests, examinations and treatments will be explained to me and that I have the right to ask questions and decline treatment unless otherwise required for public health or emergency purposes.

Financial Responsibility and Assignment of Benefits: I accept financial responsibility for services rendered. I authorize payment of medical benefits to the provider for services furnished. I understand I remain responsible for any portion not covered or payable by my insurer, including co-payments, deductibles and non-covered services.

Release of Information: I authorize the release of medical information necessary to process insurance claims and for continuity of care. I understand that information released may include records relating to mental health, substance use, HIV/AIDS status, and other sensitive conditions as permitted by law.

HIPAA Acknowledgment and Authorization to Disclose

I acknowledge that I have been offered a copy of the practice's Notice of Privacy Practices describing how my protected health information may be used and disclosed. I understand that the practice may use my health information for treatment, payment and healthcare operations, and other uses as permitted or required by law.

I authorize the practice to communicate with me by phone, voicemail, or electronic means at the contact numbers or addresses I provide. I understand that such communications may include appointment reminders, test results, billing information and health-related instructions. I may revoke this authorization at any time in writing, except to the extent that the practice has already relied on it.

Authorization to Obtain/Release Medical Records

I authorize the practice to obtain or release medical records and relevant information to other healthcare providers, payers, and entities involved in my care for the purpose of continuity of treatment, operations, and payment. This authorization includes but is not limited to consultation notes, laboratory results, imaging reports, and medication histories.

Acknowledgments and Certifications

I certify that the information provided on this form is true and accurate to the best of my knowledge. I understand that intentional falsification of information may result in denial of services or termination of the patient-provider relationship. I understand I may withdraw any authorization in writing, and that withdrawal will not affect disclosures already made in reliance on this authorization.

I understand that consenting to treatment and authorizing release of information are separate decisions; I may decline one without affecting the other except as limited by law or as necessary for treatment in an emergency.

Patient or Authorized Representative

By signing below, I acknowledge that I have read and understand this Healthcare Onboarding Form, and I consent to the terms and authorizations contained herein to the extent indicated by my signature.

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