Healthcare Patient Intake Packet

Healthcare Patient Intake Packet

Patient Information

Patient Name:    Date of Birth:

Phone:    Email:

Male    Female    Other    Prefer not to say

Relationship:    Phone:

Insurance Information

Policy/ID Number:    Group Number:

Subscriber DOB:

Medical History

Current medications (list name, dose, frequency):

Allergies (medications, food, environmental) and reactions:

Diabetes    Hypertension    Heart disease    Asthma    Cancer    Mental health condition    None of the above

Consent for Treatment

I authorize healthcare providers at this facility to perform diagnostic and therapeutic procedures as deemed necessary in the course of my care. I understand that all procedures involve some degree of risk and that no guarantees have been made regarding the results. I have had the opportunity to ask questions and understand the nature, risks, and alternatives to the proposed care.

I understand that I may withdraw this consent at any time by providing written notice, except where action has already been taken in reliance on my consent.

Yes    No

HIPAA Authorization / Release of Information

I authorize the release of my protected health information to persons or entities as required for treatment, payment, and healthcare operations. I understand that information released may include medical history, test results, treatment records, and billing information.

This authorization will remain in effect until: . I understand I may revoke this authorization at any time by submitting a written revocation, except to the extent that action has already been taken in reliance on this authorization.

Financial Responsibility & Assignment

I certify that the information provided is true and complete to the best of my knowledge. I accept responsibility for charges not covered by insurance and agree to pay any co-payments, deductibles, and charges for non-covered services. I authorize payment of benefits directly to the provider for services rendered.

Responsible party phone:

Additional Administrative Information

Pharmacy phone:

Patient Acknowledgement and Certification

By signing below I certify that I have read and understand the information provided in this intake packet. I certify that the information I have provided is accurate and complete. I understand that falsification or omission of information may affect my care and may be grounds for denial of future services.

Sign Now