Healthcare Reaffirmation Form

HEALTHCARE REAFFIRMATION FORM

Facility / Provider

Patient Information

Patient Name:    Date of Birth:

Insurance Information

Medical History Update

Since my last visit, the following information has changed:

  Contact information
  Insurance coverage
  Medications
  Allergies
  Other (see notes below)

Reaffirmations and Authorizations

By checking the boxes below, I reaffirm current consents and authorizations previously provided to the named facility and certify that the information on file is accurate to the best of my knowledge.

  I reaffirm that my contact and demographic information on file is accurate.
  I reaffirm my consent to receive routine and emergency medical treatment as may be necessary.
  I reaffirm authorization for the facility to release medical information to designated persons or entities for treatment, payment, or healthcare operations as previously authorized.
  I confirm that my advance directives (if any) on file remain accurate and are to be followed.
  I reaffirm that the insurance and billing information on file is accurate and grant assignment of benefits where applicable.

HIPAA / Privacy Notice Acknowledgment

I acknowledge that I have been provided with or previously received the facility's Notice of Privacy Practices describing how my protected health information may be used and disclosed. I understand my rights to request restrictions, to receive confidential communications, and to revoke authorizations in writing, subject to the facility's policies and applicable law.

  I acknowledge receipt of the Notice of Privacy Practices or prior notification of its availability.

Authorization Duration

The authorizations and confirmations made on this form remain effective until the following date unless revoked in writing:    If left blank, authorizations remain in effect until revoked in writing.

Additional Notes / Patient Statements

Certification and Consent

I certify that the information provided on this Healthcare Reaffirmation Form is true and correct. I understand that I may withdraw or modify any authorization provided herein at any time by submitting a signed written revocation to the facility, except to the extent that the facility has already acted in reliance on this authorization. I understand that revocation will not affect disclosures made in reliance on this authorization prior to receipt of the revocation.

I authorize the facility and its agents to use and disclose my protected health information as indicated above for purposes of treatment, payment, and health care operations consistent with the facility's policies and current authorizations on file.

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