Healthcare Pre-Appt Pack

Healthcare Pre-Appt Pack

This packet collects patient demographic, insurance and clinical screening information required to prepare for a scheduled appointment and obtain necessary authorizations for treatment and release of protected health information. Complete all fields accurately. If a field does not apply, mark N/A.

Patient Information

Date of birth:    Gender:

Emergency Contact

Relationship:    Phone:

Appointment Details

Appointment date:    Appointment time:

Insurance Information

Policy number:    Group number:

Subscriber DOB:    Relationship to patient:

Medical History

Pre-Appointment Screening

In the past 14 days, have you experienced any of the following? Please check all that apply:

Fever or chills

New or worsening cough

Shortness of breath or difficulty breathing

Known exposure to infectious illness

Consents and Authorizations

Consent to Treatment: I authorize clinicians and staff at the facility to perform diagnostic procedures and medical treatment as deemed necessary by the treating provider for the episode of care related to the appointment. I understand that no specific procedure is authorized without separate informed consent where required by law. By checking the box below I provide authorization.

I consent to necessary evaluation and treatment

Telehealth Consent: If telehealth services are offered, I consent to clinical communication using remote technologies for this visit. I understand there are limitations, and I may decline telehealth and request an in-person visit.

I consent to telehealth services when offered

Authorization to Release Health Information: I authorize release of my protected health information for treatment, payment, and healthcare operations to entities involved in my care and as required by law. This authorization includes disclosure of records necessary to process insurance claims and to coordinate care.

I authorize release of PHI for treatment, payment and operations

Assignment of Benefits / Financial Responsibility: I authorize payment of insurance benefits to the provider for services rendered. I accept responsibility for charges not covered by insurance, including co-payments, co-insurance and deductibles. I authorize the provider to bill my insurance and to obtain information necessary to process claims.

I acknowledge financial responsibility and assignment of benefits

HIPAA Authorization & Privacy Acknowledgement

Acknowledgement of Privacy Practices: I acknowledge that I have received or been offered a copy of the provider's Notice of Privacy Practices describing how my medical information may be used and disclosed and how I can access this information. I understand that I may request restrictions on certain uses and disclosures, and I may revoke authorizations in writing except to the extent the provider has already acted in reliance on the authorization.

Authorization Expiration Date: This authorization to use and disclose protected health information expires on . If no date is provided, authorization expires one year from signature unless revoked earlier.

Additional Authorizations

Photographs and Recordings: I authorize the facility to take clinical photographs or recordings of the patient when necessary for documentation, treatment, education, or quality improvement. Images shall be treated as part of the medical record and used or disclosed only as permitted by law.

I consent to clinical photographs/recordings as described

Certifications

By signing below I certify that the information provided in this Pre-Appointment Pack is true and complete to the best of my knowledge. I understand that falsifying information may result in denial or delay of care. I understand my rights to revoke authorizations in writing, and that revocation does not affect disclosures already made in reliance on this authorization. I understand that I may be financially responsible for services rendered that are not covered by insurance.

Sign Now