Healthcare Patient Packet

HEALTHCARE PATIENT PACKET

Patient Information

Emergency Contact

Insurance Information

Medical History

Consent for Treatment

I authorize providers and staff of this practice to provide medical care and services as are necessary for diagnosis and treatment. This authorization includes routine diagnostic procedures, administration of medications, immunizations, minor procedures, and use of medical devices when clinically indicated.

Risks and benefits: I understand that all procedures carry potential risks and benefits. The clinician has explained the nature and purpose of the proposed care, common risks, potential complications, and reasonable alternatives, including the option of no treatment. I have had the opportunity to ask questions and all my questions have been answered to my satisfaction.

Right to withdraw: I understand that I may withdraw my consent at any time before the procedure by notifying a member of the clinical team, except where withdrawal would jeopardize safe care.

By checking this box I give my informed consent to the treatment described above and authorize its performance by the clinical staff named by this practice.

Authorization to Release Medical Records

I authorize the release of my protected health information to the designated recipient and for the purposes stated below. This authorization permits disclosure of my medical records, including treatment notes, laboratory results, imaging reports, and billing information unless restricted below.

Types of information to be released:

HIPAA Privacy Acknowledgment

I acknowledge that I have received or been offered a copy of the practice's Notice of Privacy Practices describing how my health information is used and disclosed. I understand that the practice may use and disclose my protected health information for treatment, payment, and healthcare operations as described in that notice.

I acknowledge receipt of the Notice of Privacy Practices.

Financial Responsibility & Assignment of Benefits

I agree to be financially responsible for all charges for services provided to me that are not covered by insurance, including co-payments, deductibles, and non-covered services. I authorize payment of benefits to the provider for services rendered and assign benefits to the practice when applicable.

I authorize insurance payments to be made directly to the provider and accept financial responsibility as stated above.

Additional Disclosures & Consents

Telehealth: I consent to telehealth visits when offered. I understand the benefits and limitations of remote care.

Advance Directive: I have an advance directive I do not have an advance directive

Acknowledgement and Signature

By signing below, I certify that the information provided on this form is true and complete to the best of my knowledge. I understand that falsification of information may result in denial of services or termination of care. I authorize the release of information necessary to process insurance claims and to coordinate my medical care.

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