Healthcare Provider Questionnaire

HEALTHCARE PROVIDER QUESTIONNAIRE

Patient Information

Patient Name:   Date of Birth:   Gender:

Current Healthcare Provider(s)

Primary Care Provider:   Phone:

Insurance Information

Policy / ID Number:   Group Number:

Medical History

Reason for Visit / Clinical Information

Authorizations, Acknowledgments, and Consents

By signing below, I authorize the release and exchange of my protected health information between the above-named providers, specialists, and my insurance carrier as necessary for treatment, payment, and healthcare operations. This authorization includes medical records, diagnostic reports, laboratory results, and billing information, except as restricted below.

I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by federal privacy regulations to the extent permitted by law. I acknowledge that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it.

I give permission for the clinical team to contact my other healthcare providers to obtain prior records and consult regarding my care: Yes

I authorize the clinic to leave appointment reminders, test results, and limited health information by telephone or voicemail at the numbers provided: Yes

Authorization Expiration Date:   (If left blank, this authorization will expire one year from the date of signature.)

HIPAA Privacy Acknowledgment

I acknowledge that I have been offered a copy of the provider's Notice of Privacy Practices, which describes how my medical information may be used and disclosed and how I can get access to this information. I understand my rights as described in that notice.

I certify that the information I have provided on this Healthcare Provider Questionnaire is true and complete to the best of my knowledge. I understand that knowingly providing false information may result in denial of services or other lawful actions.

Additional Authorizations

I understand that I may request restrictions on uses and disclosures of my health information, but the provider is not required to agree to such restrictions. Any agreement to restrict disclosures will be documented in writing.

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