Healthcare Premier Form

HEALTHCARE PREMIER FORM

PATIENT INFORMATION

Patient Name:

Date of Birth:    Gender: Female Male Other

INSURANCE INFORMATION

MEDICAL HISTORY & CURRENT HEALTH

Do you have any of the following chronic conditions? (check all that apply)

Diabetes    Hypertension    Heart Disease    Asthma/COPD    None of the above

CONSENT FOR TREATMENT

I authorize Healthcare Premier Form clinicians and ancillary personnel to provide medical evaluation, diagnostic testing, emergency treatment and routine care as medically necessary. I understand that treatment recommendations, risks, benefits and alternatives will be explained to me prior to non-emergent procedures, and I have the right to ask questions and refuse any treatment.

I acknowledge that no guarantee has been made to me regarding the outcome of treatments. I accept responsibility for following recommended instructions and for notifying the clinician of any changes in my condition or reactions to treatment.

Consent to General Treatment: I consent to general medical treatment and diagnostic services.

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION & HIPAA ACKNOWLEDGMENT

I authorize the disclosure of protected health information as necessary to carry out treatment, payment and healthcare operations. This authorization permits release of medical records, billing information, and relevant clinical data to insurance carriers, referring providers, and other entities directly involved in care or payment.

Purpose of Disclosure:

Expiration: This authorization will expire on or upon earlier written revocation submitted to the provider. I understand that revocation will not affect disclosures made prior to receipt of the revocation.

I acknowledge receipt of the facility's Privacy Practices Notice and understand my rights to access and obtain copies of my medical record, request restrictions, request confidential communications, and to submit complaints if I believe my rights have been violated.

FINANCIAL RESPONSIBILITY & ASSIGNMENT OF BENEFITS

I am financially responsible for all charges for services provided to me that are not covered or paid by my insurance. I authorize benefits to be paid directly to the provider for services furnished to me and certify that the information I have provided about insurance coverage is accurate and complete to the best of my knowledge.

Assignment of Benefits: I assign insurance benefits to be paid to the provider and authorize release of information necessary to process claims.

If applicable, I agree to pay applicable co-payments, deductibles and non-covered services. I understand that failure to pay may result in collection activity in accordance with provider policy.

ADDITIONAL AUTHORIZATIONS / NOTICES

By signing below, I certify that I have read and understood the information on this form, that the information I provided is true and complete to the best of my knowledge, and that I consent to the uses and disclosures described above. I understand that I may revoke authorizations in writing except to the extent that action has already been taken in reliance on them.

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