Healthcare Onboarding Profile

Healthcare Onboarding Profile

Patient Information

Patient Name:

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

Emergency Contact

Insurance Information

Medical History

Current Medications (include dose and frequency):

Allergies (select all that apply):

Medication Food Latex Contrast dye None

Prior surgeries or hospitalizations (include approximate dates):

Chronic medical conditions (select all that apply):

Diabetes Hypertension Heart disease Asthma / COPD Cancer Psychiatric condition None

Provider and Care Coordination

Authorizations, Consents, and Acknowledgements

Consent to Treatment: I authorize clinicians, medical staff, and authorized personnel of this practice to provide care, examinations, diagnostic procedures, and treatment as deemed necessary for my health. I understand that no medical or surgical procedure is entirely risk free. I have been given the opportunity to ask questions regarding recommended care and anticipated risks and benefits.

Assignment of Benefits and Financial Responsibility: I authorize payment of medical benefits to the provider for services rendered. I accept financial responsibility for charges not covered by insurance, including co-payments, deductibles, and services denied as not medically necessary. I understand I may be billed directly for unpaid balances.

Release of Information: I authorize the release of my medical information to insurers, referring providers, and other health care entities for purposes of treatment, payment, and health care operations. I understand this release may include information related to mental health, substance use treatment, and communicable diseases where permissible by law.

HIPAA Acknowledgement: I acknowledge receipt of the practice's Notice of Privacy Practices and understand how my protected health information may be used and disclosed. I understand my rights to request restrictions, access my records, and revoke authorizations except to the extent action has already been taken.

Permission to Leave Messages and Communications: Permit leaving test/voice messages at primary phone Permit text message reminders Permit email communication

Authorization to Obtain Records: By signing below I authorize the practice to obtain relevant medical records from prior providers for continuity of care. This authorization expires on:

Revocation: I understand I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance upon it. This authorization will otherwise remain in effect until the date specified above or until revoked in writing.

Accuracy Certification: I certify that the information I have provided on this form is true and correct to the best of my knowledge. I agree to notify the practice of any changes to this information.

By signing below I indicate that I have read and understand the foregoing authorizations, consents, and acknowledgements and accept their terms.

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