Healthcare Personal Injury Packet

HEALTHCARE PERSONAL INJURY PACKET

Patient Information

Date of Birth:   Gender:

Insurance & Responsible Party

Is this injury related to motor vehicle collision, workers' compensation, or third-party liability? Motor vehicle Workers' compensation Third-party liability

Incident / Injury Details

Date of Incident:   Time of Incident:

Primary Injured Body Part(s):

Medical History

Consent for Treatment

I, the undersigned patient or authorized representative, authorize the medical staff and agents of the treating provider to perform diagnostic and therapeutic procedures as deemed necessary for evaluation and treatment of my personal injury. I understand that treatment may include, but is not limited to, physical examination, imaging studies, injections, wound care, splinting, and medications.

I acknowledge that no guarantees have been made to me regarding the results of any treatment. I have had the opportunity to ask questions regarding the nature, risks, benefits, and alternatives to proposed care and those questions have been answered to my satisfaction.

Authorization to Release Records & Assignment of Benefits

I authorize the release of my medical records, radiographs, reports, bills, and other information related to the treatment of this injury to insurers, legal representatives, and other health care providers as necessary for the purpose of payment, claims processing, or legal action arising from this incident. This authorization includes disclosure of substance use, psychiatric, and HIV-related information when relevant to care.

I hereby assign and convey to the treating provider all rights to payments and benefits payable for services rendered for this injury to the extent permitted by law. I consent to the provider's release of information necessary to secure payment. If my claim results in third-party recovery, I authorize the provider to pursue collection or place a lien on proceeds as permitted by applicable law to satisfy outstanding balances for services rendered.

HIPAA Acknowledgment

I acknowledge receipt of the facility's Notice of Privacy Practices, and I understand my rights with respect to use and disclosure of my protected health information. I understand that I may request restrictions on certain uses and disclosures and that this authorization may be revoked in writing except to the extent that action has already been taken in reliance upon it.

By checking the box below I indicate my acknowledgment and agreement: I acknowledge receipt of the Notice of Privacy Practices

Financial Responsibility

I understand that I am financially responsible for all charges not paid by insurance or third parties, including deductibles, co-payments, co-insurance, and non-covered services. If my claim is a third-party or liability matter, I agree to cooperate in providing documentation and assigning benefits to the provider as described above. I understand that collection of outstanding balances may include placement of a lien on settlement proceeds as permitted by law.

I authorize payment of medical benefits directly to the treating provider for services furnished to me. This authorization is a contract between myself and the treating provider and survives my death or incapacity to the extent required by law.

Legal Certifications

I certify under penalty of perjury that the information provided in this packet is true, accurate, and complete to the best of my knowledge. I understand that knowingly providing false information may subject me to civil or criminal penalties and may adversely affect my eligibility for benefits.

Sign Now