Healthcare Prevention Services Form

HEALTHCARE PREVENTION SERVICES FORM

Patient Information

Date of Birth:     Gender:

Primary Phone:     Alternate Phone:

Relationship:     Phone:

Insurance Information

Policy Number:     Group Number:

Preventive Services Requested

Select the preventive services you are requesting today (check all that apply):

Influenza (Flu) vaccine    Tdap vaccine    HPV vaccine

COVID-19 vaccine or booster    Cervical cytology (Pap test)    Mammogram referral

Blood pressure screening    Cholesterol screening    Diabetes screening (A1c)

Medical History (Relevant to Preventive Care)

Consent for Preventive Services

I hereby request and authorize the healthcare provider and personnel to administer the preventive services I have selected above. I understand that:

• Preventive services are intended to reduce the risk of disease and identify health concerns early; results cannot be guaranteed.
• All treatments and vaccines carry potential risks and side effects; known common risks have been explained to me and I have had the opportunity to ask questions.
• I may refuse or withdraw consent to any service at any time. Withdrawal of consent will not affect my right to future care.
• The provider will document services in my medical record and may share pertinent information with other treating providers for continuity of care.

By checking the box below I consent to administration of the selected preventive services and authorize billing of my insurance, if applicable.
I consent to the provision and billing of the selected preventive services.

Authorization to Obtain and Release Information

I authorize the release of relevant medical information necessary for the administration of preventive services and for billing and payment purposes to my insurance carrier and to other healthcare providers involved in my care.

This authorization will expire on:     I understand that I may revoke this authorization at any time by submitting a written revocation to the provider, except to the extent that action has already been taken in reliance on this authorization.

Privacy Notice Acknowledgment

I acknowledge that I have been offered or provided the facility's Notice of Privacy Practices describing how my medical information may be used and disclosed. I understand my rights regarding my health information as explained in that notice.
I acknowledge receipt of the Notice of Privacy Practices.

Patient Certification

I certify that the information I have provided on this form is true and correct to the best of my knowledge. I understand that false statements may affect my eligibility for services or insurance benefits.

I certify that the information provided is complete and accurate.

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