Healthcare PACT Form

Healthcare PACT Form

Patient Information

Patient Name:

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

Emergency Contact

Insurance Information

Medical History

PACT Services, Consent, and Patient Responsibilities

The Patient Aligned Care Team (PACT) model provides coordinated primary care and related services. As a patient enrolled in PACT, I understand that my care team may include primary care providers, nurses, behavioral health clinicians, pharmacists, social workers, and other allied health professionals employed or contracted by the clinic.

By signing this form I consent to receive routine and emergency care provided by members of my PACT. I understand risks and benefits of proposed treatments will be explained when applicable, and I retain the right to refuse or withdraw consent for non-emergent treatments at any time. Withdrawal of consent must be provided in writing to the clinic unless otherwise impracticable for urgent care.

I agree to the following patient responsibilities: keep scheduled appointments or notify the clinic within the required timeframe for cancellations; provide accurate and complete health information; follow agreed treatment plans to the best of my ability; and notify the clinic of changes in my contact information or insurance coverage.

I hereby give consent for routine diagnostic and therapeutic procedures as ordered by my PACT clinicians. I understand that certain procedures may carry risks which will be explained to me prior to performance when feasible.

I consent to treatment by my PACT
I consent to receive telehealth services when clinically appropriate
I consent to receive appointment reminders and clinic messages by phone or text
I consent to exchange relevant health information among my PACT members for coordination of care

Privacy, Release, and Authorization

I acknowledge receipt of the clinic's Privacy Practices notice and understand that my protected health information may be used and disclosed for treatment, payment, and health care operations as described in that notice. I authorize the clinic to release medical information to other health care providers, insurers, and my designated contacts as necessary for my care and billing unless I have restricted disclosure in writing.

I authorize the clinic to discuss my medical information with the following person(s):

This authorization will remain in effect until the date specified below or until I submit a written revocation to the clinic. I understand that revocation will not apply to information already released in reliance on this authorization.

Financial Responsibility and Appointment Policy

I accept financial responsibility for services rendered that are not covered or paid by my insurer. I understand co-payments, deductibles, and non-covered services are my responsibility. I agree to provide accurate insurance information and to promptly notify the clinic of changes.

I understand the clinic's appointment cancellation and no-show policy: failure to attend or timely cancel appointments may result in documentation of missed appointments, potential discharge from routine clinic scheduling, or other administrative actions consistent with clinic policy.

Acknowledgment and Certification

By signing below 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 care and eligibility for benefits. I have had the opportunity to ask questions and have received answers regarding the PACT model, privacy practices, and the above authorizations.

I acknowledge receipt of the clinic's Privacy Practices notice and understand my rights regarding protected health information.

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