Healthcare Policy Review

HEALTHCARE POLICY REVIEW

Patient Information

Insurance Information

Medical History (Brief)

Policy Acknowledgments (Select all that apply)

I hereby acknowledge that I have reviewed and understand the following provider policies and procedures. By checking each box I confirm I have had the opportunity to ask questions and receive answers.

I acknowledge receipt of the Notice of Privacy Practices and understand how my protected health information may be used and disclosed for treatment, payment, and health care operations.

I understand the provider's payment policy: I am responsible for copayments, coinsurance, and any charges not covered by my insurer. I authorize the provider to bill my insurance and to collect balances due.

I have reviewed the appointment cancellation and no-show policy, including potential fees for missed appointments when sufficient notice is not provided.

I understand the telehealth policy, including limitations of virtual visits, potential technical failures, and privacy considerations.

I authorize release of medical information to other health care providers as necessary for continuity of care, and I understand that additional written authorization will be required for most disclosures unrelated to treatment, payment, or operations.

I consent to electronic communications related to scheduling, billing, and limited clinical messaging, recognizing that such communications may not be fully secure.

I have been informed of the provider's grievance and complaint procedure and how to submit a grievance regarding care or service received.

Policy Details & Important Notices

Billing and Collections: The patient is responsible for all charges not paid by an insurer within a reasonable billing period. If accounts are placed for outside collection, the patient agrees to pay collection costs and reasonable attorney's fees where permitted by law. Insurance benefits are assigned to the provider when applicable; however assignment does not relieve the patient of primary financial responsibility.

Privacy and Use of Health Information: The provider will use and disclose protected health information in accordance with the Notice of Privacy Practices. The patient has the right to request restrictions, request confidential communications, and inspect or copy health records as allowed by law. Requests for restrictions or account disclosures must be submitted in writing as specified by the provider's internal procedures.

Consent & Withdrawal: This document confirms review of policies and is not a clinical consent for procedures. The patient may withdraw acknowledgements in writing; withdrawal will not affect disclosures or actions already taken in reliance on the acknowledgements prior to the provider's receipt of the written withdrawal. Certain obligations, including payment of services rendered, may continue after withdrawal.

Reviewer Comments

Authorization and Expiration

This acknowledgment of policy review is effective on the date signed below and remains in effect unless revoked in writing. If an expiration date is specified below, this document will expire on that date and the patient must re-review and re-acknowledge provider policies thereafter.

Certification: By signing below I certify that I have reviewed the provider policies indicated above, that I understand them to the extent explained to me, and that I accept financial responsibility as described. If signing as a personal representative, I certify that I have authority to sign on behalf of the patient and that supporting documentation is on file with the provider.

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