Healthcare Onboarding Packet

Healthcare Onboarding Packet

Patient Information

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

Emergency Contact

Insurance Information

Subscriber Date of Birth:    Insurance Phone:

Medical History

Social & Behavioral Health

Tobacco use: Never Current Former

Alcohol use: None Social Regular

Consent for Treatment and Authorizations

I authorize the clinicians and staff of this practice to provide routine medical care, diagnostic procedures, treatment, and emergency care as deemed necessary. I understand that no guarantee has been made concerning the results of any examination or treatment.

I acknowledge that I have the right to be informed of the nature and purpose of proposed procedures and treatments, the significant risks and expected benefits, and reasonable alternatives. I acknowledge the right to withdraw consent at any time prior to a procedure, except where withdrawal would jeopardize my health or safety.

By checking the box below I give my informed consent to receive medical treatment as described above.

I consent to treatment and procedures as necessary.

Authorization to Release Medical Information

I authorize the release of my protected health information to the person(s) or organization(s) named below for the specific purpose indicated. This authorization includes records relating to communicable diseases, mental health, alcohol or substance use treatment, and HIV/AIDS testing and results unless I specifically revoke such categories by initialing below.

Release expires on:

I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by federal privacy laws.

HIPAA Privacy Acknowledgement

I acknowledge receipt of the Notice of Privacy Practices describing how my protected health information may be used and disclosed and how I can obtain access to this information. I understand that the practice may use and disclose my medical information for treatment, payment, and health care operations as described in that notice.

I acknowledge receipt of the Notice of Privacy Practices.

Financial Responsibility & Assignment of Benefits

By signing below, I agree to be financially responsible for charges not covered by my insurance, including co-payments, deductibles, and non-covered services. I authorize the release of medical information necessary to process insurance claims and request that payment of authorized benefits be made on my behalf to this practice.

I authorize assignment of benefits and accept financial responsibility as stated.

Telehealth Consent

I consent to receive health care services via telehealth when recommended by my provider. I understand the potential benefits and limitations of telehealth, including the possibility of technical failures and limitations to privacy.

I consent to telehealth services.

Additional Authorizations

I certify that the information I have provided on this form is true and accurate to the best of my knowledge. I understand that providing false information may affect my treatment and insurance coverage.

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