Healthcare Outpatient Center Document

Healthcare Outpatient Center Document

Patient Information

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History

Primary Care Physician:    Last visit date:

Consent for Treatment

I hereby authorize qualified clinicians and staff of the outpatient center to perform examinations, diagnostic procedures and outpatient medical treatment as deemed necessary for my care. I understand that treatment may include physical examinations, laboratory testing, imaging, minor procedures and administration of medications. I acknowledge that no guarantee has been made to me as to the results of any examination or treatment.

I understand the common and material risks and benefits associated with outpatient care, including but not limited to allergic reaction to medications, infection, bleeding, and unforeseen complications. I have had the opportunity to ask questions and have received answers to my satisfaction. I understand that I may withdraw consent at any time by notifying the treating provider, except to the extent that action has already been taken in reliance on this consent.

By checking this box I consent to the outpatient evaluation and treatment described above and acknowledge my understanding of the risks, benefits and alternatives.

Authorization to Release Medical Information

I authorize the outpatient center to release my medical information, including medical records, test results and billing information, to the following parties for purposes of treatment, payment, or healthcare operations: persons or entities listed below and my insurance payers. This authorization includes disclosure of sensitive information such as mental health, substance use treatment, HIV/AIDS-related information and communicable diseases, where permitted by law.

Authorization Expiration Date:

I authorize release of the above information as specified and understand this authorization may be revoked in writing at any time except to the extent action has been taken in reliance on this authorization.

Financial Responsibility & Assignment of Benefits

I understand that I am financially responsible for all charges not covered by my insurance, including copayments, deductibles and services denied by my insurer. I assign benefits to the outpatient center and authorize payment of medical benefits directly to the provider for services rendered. I agree to provide current insurance information and to notify the center of any changes.

I acknowledge financial responsibility and assign my insurance benefits to the outpatient center.

HIPAA Privacy Acknowledgment

I acknowledge receipt of the outpatient center's Notice of Privacy Practices describing how my protected health information may be used and disclosed and my rights under federal and state law. I understand I may request restrictions on certain uses and disclosures and request confidential communications.

I acknowledge that I have been offered or received a copy of the Notice of Privacy Practices.

Consent for Electronic Communications & Messages

The outpatient center may contact me regarding appointments, billing and treatment reminders by telephone, SMS/text message, or email. I understand standard cellular or internet charges may apply.

I consent to receive electronic communications and messages as described above.

Additional Authorizations & Declarations

I certify under penalty of perjury that the information I have provided on this form is true and complete to the best of my knowledge. I understand that falsification of information may result in denial of services or other legal consequences.

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