Healthcare Patient Agreement

Healthcare Patient Agreement

Patient Name:    Date of Birth:    Gender: Female Male Other/Decline

Contact & Demographic Information

Emergency Contact

Insurance Information

Relevant Medical History

Consent for Treatment & Acknowledgements

I hereby authorize the physicians, advanced practice providers, nurses and staff of this practice to provide such medical care, examinations and treatment as, in their judgment, is necessary or advisable for my health. I understand that no guarantee has been made as to the results of any treatment or examination.

Patient Initials:

I understand that the practice will explain the expected benefits, the common and serious risks, and reasonable alternatives to the proposed procedure. I have had the opportunity to ask questions and all my questions have been answered to my satisfaction. I retain the right to withdraw consent at any time prior to the initiation of treatment by delivering a written revocation to the treating provider; such revocation will not affect actions already taken in reliance on this consent.

Financial Responsibility & Assignment of Benefits

I agree that I am financially responsible for all charges for services provided to me by this practice whether or not paid by insurance. I assign to the practice the right to receive and retain payment from my insurer(s) for services rendered. I authorize my insurer(s) to release any information required to process claims and to make payment directly to the practice. I understand that co-payments, deductibles, co-insurance and services denied as not medically necessary are my responsibility.

Assignment of Benefits: I authorize direct payment from my insurer(s) to the practice.

Authorization to Release Medical Information

I authorize the practice to use and disclose my health information as necessary for treatment, payment, and health care operations, and to release my medical records to other health care providers, insurers, and persons I designate. This authorization includes release of information related to mental health, substance use, HIV/AIDS status, and genetic testing where applicable, unless I have specifically restricted such release in writing.

Release Authorization: I authorize release of my records as described above.

Privacy Notice & Communication Preferences

I acknowledge receipt of the practice's Notice of Privacy Practices and understand how my medical information may be used and disclosed. I understand I may request restrictions on certain uses or disclosures of my protected health information, and that such requests must be submitted in writing.

HIPAA Acknowledgement: I acknowledge receipt of the Notice of Privacy Practices.

Communication Consent: I authorize the practice to contact me at the phone number and email provided for appointment reminders, billing, and health information. Choose preferred methods: Phone Text message Email

No-Show / Cancellation Policy

I understand that I am responsible for cancellations not made in accordance with the practice's cancellation policy. The practice may bill for missed appointments or late cancellations in accordance with its standard policy. Financial responsibility for such fees rests with the patient or the patient's guarantor.

Certifications and Agreement

By signing below I certify that I am the patient or an authorized representative of the patient, that the information provided above is true and accurate to the best of my knowledge, and that I have read and understand this Healthcare Patient Agreement. I agree to the terms set forth regarding consent for treatment, authorization to release information, assignment of benefits, and financial responsibility.

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