Healthcare Patient Application & Consent

Healthcare Patient Application & Consent

Patient Information

Date of Birth:    Gender: Male Female Non-Binary/Other

Emergency Contact

Insurance Information

Medical History

Drug(s)   Food(s)   Environmental   No Known Allergies

Diabetes   Hypertension   Asthma   Heart Disease   Other

Consents and Authorizations

I hereby authorize clinicians and staff of this facility to provide medical assessment, diagnostic procedures, necessary treatment, and emergency care as deemed appropriate by the treating provider. I understand that medical care involves risks and potential complications; I have had an opportunity to ask questions and have received satisfactory responses regarding the nature, risks, benefits, and alternatives to the proposed care.

I understand I may revoke this consent in writing at any time except to the extent that action has already been taken in reliance on it. I accept financial responsibility for services provided that are not covered by insurance or when insurance benefits are not assignable. I authorize assignment of insurance benefits to the provider where permitted.

By checking the boxes below I provide specific authorizations as indicated:

I consent to receive medical treatment and diagnostic services.
I consent to administration of anesthesia or sedation if indicated by the treating provider.
I consent to telehealth encounters when offered, understanding the limits and benefits of remote care.

Authorization to Release Protected Health Information (PHI)

I authorize the release of my protected health information to the following person(s) or entity(ies) for the purpose(s) stated. This authorization includes records related to treatment, billing, and insurance claims unless specifically restricted below.

I understand that I may revoke this authorization at any time by submitting a written request, except to the extent that release has already occurred in reliance on this authorization. Information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by law.

Acknowledgment of Privacy Practices

I acknowledge that I have been offered a copy of the facility's Notice of Privacy Practices describing how my health information may be used and disclosed and how I can obtain access to this information. I understand my rights regarding my protected health information.

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

Patient Certification

By signing below I certify that the information I have provided is true and correct to the best of my knowledge. I understand that withholding information or providing false information may adversely affect my care. I authorize payment of benefits to the provider when applicable and hold the provider harmless for actions taken in good faith reliance on this authorization.

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