Healthcare Pavilion Form

HEALTHCARE PAVILION FORM

Patient Information

Patient Name:

Date of Birth:    Gender: Male   Female   Other

Emergency Contact

Insurance Information

Medical History

Chronic Conditions (check all that apply):   Diabetes   Hypertension   Heart disease   Asthma   None

Consent for Treatment

I authorize Healthcare Pavilion and its physicians, nurses and staff to perform medical evaluation, diagnostic tests, and treatments as deemed necessary by the attending provider. I understand that the nature and purpose of the proposed treatment, expected benefits, material risks, and reasonable alternatives (including no treatment) have been explained to me and that no guarantees have been made concerning results.

I acknowledge that I have the right to ask questions about my care, to receive answers in understandable terms, and to refuse or withdraw consent at any time prior to the procedure or treatment. Withdrawing consent may affect the provision of services and could result in discharge if treatment is refused and continued care is deemed unsafe.

Authorization to Release Medical Information

I authorize Healthcare Pavilion to release protected health information to the following recipient(s) for the purpose(s) indicated. This authorization includes information related to diagnoses, treatments, and billing records unless specifically excluded below.

Exclude the following types of information from release (check if applicable):   HIV-related   Substance use treatment   Mental health psychotherapy notes

This authorization will expire on: or upon the following event:

I understand that I may revoke this authorization at any time by signing a written revocation and delivering it to Healthcare Pavilion's medical records department, except to the extent that action has already been taken in reliance on this authorization.

HIPAA Privacy Acknowledgment

I acknowledge that I have been offered a copy of the Notice of Privacy Practices describing how my protected health information may be used and disclosed, and my rights regarding that information under applicable privacy laws. I understand that Healthcare Pavilion may use and disclose my health information for treatment, payment, and health care operations as described in the Notice.

Permission to leave appointment reminders or health information by telephone or voicemail: Yes    No

Financial Responsibility and Assignment

By signing below I accept financial responsibility for services provided by Healthcare Pavilion that are not paid by my insurer. I authorize payment of benefits directly to Healthcare Pavilion for services rendered and permit the release of any medical information necessary to process claims. I understand that I remain responsible for any co-payments, deductibles, co-insurance, and non-covered services.

If I am signing on behalf of the patient as a parent or legal guardian, I certify that I have the legal authority to consent to treatment and to authorize release of medical information and financial responsibility.

Patient Rights & Complaints

Patients have the right to receive respectful, safe and confidential care, to receive an explanation of their rights and responsibilities, and to file complaints about care or billing practices without reprisal. Complaints should be submitted in writing to the facility patient relations office.

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