Healthcare Policies Form

HEALTHCARE POLICIES FORM

Patient Name:   Date of Birth:   Gender: Male Female Other/Prefer not to say

Emergency Contact

Insurance Information

Medical History (brief)

Practice Policies & Patient Acknowledgment

1. Financial Responsibility

The patient is financially responsible for all charges for services rendered. Insurance benefits are a contract between the insurer and the insured; the practice will bill insurance as a courtesy. Any deductible, co-payment, co-insurance, or non-covered services are due at the time of service. If the account becomes delinquent and is placed with a collection agency, the patient agrees to pay reasonable collection costs, attorney fees, and interest to the extent permitted by law.

I acknowledge and agree to the Financial Responsibility policy.

2. Payment, Billing and Refunds

Payment is due at the time services are provided unless prior written arrangements are made. If an overpayment is discovered, refunds will be issued in compliance with applicable law and internal refund policy. Disputed charges must be reported in writing within 60 days of the statement date.

I acknowledge and agree to the Payment, Billing and Refunds policy.

3. Appointment Cancellation / No-Show

A minimum of 24 hours' notice is required to cancel or reschedule non-emergent appointments. Failure to provide adequate notice may result in a cancellation fee. The patient may be discharged from the practice after repeated missed appointments or failure to comply with scheduling policies.

Fee for missed appointment (if applicable): $

I acknowledge and agree to the Appointment Cancellation / No-Show policy.

4. Prescription and Controlled Substances Policy

All prescriptions, particularly for controlled substances, are issued in accordance with applicable statutes and clinical judgment. Early refill requests may be denied. Lost or stolen prescriptions will not be routinely replaced. The practice maintains the right to discontinue controlled substance prescriptions if there is evidence of misuse or diversion.

I acknowledge and agree to the Prescription and Controlled Substances Policy.

5. Telehealth / Remote Care

Telehealth services may be offered when clinically appropriate. Telehealth has limitations compared to in-person visits and may not be appropriate for all conditions. The patient consents to the use of telehealth when recommended and understands billing practices for telehealth visits.

I acknowledge and agree to the Telehealth / Remote Care policy.

6. Privacy and HIPAA Acknowledgment

The practice maintains a Notice of Privacy Practices describing how protected health information may be used and disclosed. By signing below, the patient acknowledges receipt of the Notice of Privacy Practices or that the patient was offered the notice and declined to accept a copy.

I acknowledge receipt of, or offer of, the Notice of Privacy Practices.

7. Release of Records / Authorization

Where the patient authorizes release of medical information to third parties, this practice will comply only with a signed authorization specifying the recipient and scope of information. This authorization may be revoked in writing at any time, except to the extent the practice has already acted in reliance on it.

8. Consent to Treatment

I consent to routine diagnostic and therapeutic procedures and to any emergency medical care deemed necessary by treating clinicians. I understand that all clinical procedures involve some degree of risk and that no guarantees have been made concerning outcomes.

I consent to evaluation and treatment as described above.

Patient Certification

By signing below, I certify that the information provided on this form is accurate to the best of my knowledge, that I have read and accept the practice policies set forth above, and that I am authorized to sign this form. I understand that this form will be kept in my medical record.

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