Healthcare Reappointment Approval Packet

HEALTHCARE REAPPOINTMENT APPROVAL PACKET

Patient Identification

Patient Name:

Female Male Non-binary/Other Prefer not to answer

Insurance Information

Medical History Update

Reappointment Request & Service Details

Reason for Reappointment / Services Requested:

Preferred reappointment date:    Preferred time of day:

Consent to Continue Care and Acknowledgments

By signing below I certify that the information provided in this packet is true and complete to the best of my knowledge. I request reappointment to continue receiving care or services from the provider or program named herein. I understand that reappointment does not guarantee appointment availability and that scheduling is subject to provider availability and program capacity.

I authorize the continuing provision of care and any routine diagnostic or therapeutic procedures deemed necessary by my treating clinician. I acknowledge that no guarantee has been made to me regarding the result of treatment. I understand the general risks and benefits associated with continued care, including possible complications, and I have had the opportunity to ask questions and receive answers.

I understand I may withdraw this request for reappointment at any time by delivering written notice to the provider or health center. Withdrawal will not affect any actions taken in reliance on this approval prior to receipt of such notice.

I acknowledge that I have been offered a copy of the Notice of Privacy Practices and understand how my protected health information may be used and disclosed in relation to continued care.

Communication Preferences (check all that apply):

Phone Text Message Email Postal Mail

Authorization to Release and Obtain Medical Information

I authorize my health care providers and my insurance plan to release and request medical and billing information necessary to process this request for reappointment and to facilitate coordination of care. This authorization includes release of problem lists, medication records, and relevant diagnostic reports.

I understand that this authorization is voluntary and that I may revoke it at any time except to the extent that action has already been taken in reliance on it. A revocation must be submitted in writing.

Administrative Use & Additional Declarations

Has the patient had any changes in insurance, address, or primary care provider since last visit? Yes No

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