Healthcare Paper Document

PATIENT CONSENT, AUTHORIZATION & INTAKE FORM

Patient Information

Insurance Information

Medical History

Consent for Treatment

I, , hereby authorize the clinical staff of this practice to perform the following procedure(s) and/or treatment(s):

I acknowledge that the nature and purpose of the procedure(s) have been explained to me, including the expected benefits, potential risks, common complications, and reasonable alternatives. I understand that no guarantee has been made as to the outcome of the procedure(s). I have had the opportunity to ask questions and all of my questions have been answered to my satisfaction.

I understand that I have the right to refuse or withdraw consent at any time prior to the procedure without affecting my right to future care or treatment. If I withdraw consent, I shall notify the treating clinician immediately.

Authorization to Use and Disclose Protected Health Information (PHI)

I authorize disclosure of my protected health information as described below. This authorization is voluntary and is not a condition of treatment. The recipient of the information will not be prohibited from re-disclosing the information unless applicable law restricts such re-disclosure.

Scope of information to be released (check all that apply):

Full medical record
Laboratory results
Imaging reports
Billing and insurance records
Specific information:

Purpose of disclosure:

This authorization will expire on: . If no date is provided, this authorization will expire one year from the date of signature.

I understand that I may revoke this authorization at any time by submitting a written revocation to the practice's privacy officer. Revocation will not apply to disclosures already made in reliance on this authorization prior to receipt of the revocation.

HIPAA Privacy Acknowledgment & Financial Responsibility

I acknowledge receipt of the practice's Notice of Privacy Practices. I understand my rights regarding the privacy and disclosure of my health information and that I may request restrictions on certain uses and disclosures, subject to applicable law.

I agree to be financially responsible for services rendered and understand that I am responsible for any charges not covered or paid by my insurance carrier. I authorize assignment of benefits to the provider and direct payment to the provider by my insurer when applicable.

By signing below I certify that the information provided on this form is true and complete to the best of my knowledge, that I have read and understand the statements above, and that I consent to the treatments and authorizations as indicated.

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