Healthcare Practice Prerogatives

HEALTHCARE PRACTICE PREROGATIVES

Practice Name:    Patient Name:

Patient Information

Insurance Information

Medical History Snapshot

Statement of Practice Prerogatives — Acknowledgment and Consent

The undersigned acknowledges that the practice maintains certain clinical, administrative and operational prerogatives necessary to deliver safe and effective care. By initialing or checking each applicable box below and signing at the end of this document, I acknowledge that I have read and understand these prerogatives and that they may apply to my care as indicated by my provider.

The practice retains sole authority to determine scope of services, appropriate modalities of treatment, assignment of clinical staff and delegation of duties to qualified personnel in accordance with licensing and credentialing. I acknowledge that these decisions are based on clinical judgment, best practice and applicable law.

The practice and my clinician have the prerogative to make clinical decisions, including the selection, modification or discontinuation of treatments, based on clinical assessment, standard of care, and safety considerations.

The practice may provide telehealth or electronic communications as part of care when clinically appropriate. I consent to the use of telehealth and understand limitations and risks inherent to remote care, including potential technological failures and privacy risks.

The practice may photograph or record clinical images for treatment, quality assurance, training, or documentation. Confidentiality will be maintained; identifiable images will not be used outside clinical or educational contexts without separate written consent. I consent to non-identifiable use for educational purposes unless I opt out below.

I do NOT authorize de-identified health information or images to be used for research, teaching, or publication. (If you do not check, the practice may use de-identified information for these purposes in accordance with institutional policies.)

The practice retains the right to bill for services, submit charges to insurance, and pursue collection actions consistent with law for unpaid balances. I acknowledge responsibility for timely payment and for providing accurate insurance information.

The practice may enforce appointment, no-show and cancellation policies. Repeated missed appointments or noncompliance may result in limited scheduling privileges or termination of the provider-patient relationship after appropriate notice.

In the event of an emergency or when specialized care is indicated, the practice may arrange transfer to another facility or provider and take necessary measures to stabilize care; I consent to such actions as reasonably required.

The practice may terminate the provider-patient relationship for reasons including but not limited to nonpayment, disruptive behavior, or repeated failure to follow treatment plans; termination will be documented and reasonable transition assistance provided.

The practice may disclose protected health information to other health care providers, payers, or agents as necessary for treatment, payment, or health care operations. I understand that such disclosures are governed by applicable privacy law and the practice's policies.

Privacy, Authorization and Expiration

HIPAA Acknowledgment: I acknowledge that I have been offered or provided with the Practice's Notice of Privacy Practices describing how my health information may be used and disclosed and my rights with respect to that information.

Revocation: I understand that I may revoke this acknowledgment or authorizations in writing at any time, except to the extent the practice has already acted in reliance on this acknowledgment or as otherwise permitted by law.

Patient Certification

By signing below I certify that I have read, understand, and accept the Practice Prerogatives described in this document. I acknowledge that my clinician has the authority to exercise clinical judgment and that the practice may take administrative actions described above when permitted by law and policy. I further certify that the information I have provided on this form is true and complete to the best of my knowledge.

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