Healthcare Reappointment Packet

HEALTHCARE REAPPOINTMENT PACKET

Purpose: This packet updates the patient's demographic, insurance, medical history, consent, and communication preferences prior to scheduling a reappointment. Please complete all applicable fields and sign where indicated. Inaccurate information may affect care, billing, and continuity of treatment.

Patient Information

Date of Birth: / /

Male    Female    Other    Prefer not to say

Emergency Contact

Insurance Information

Subscriber Date of Birth: / /

Medical History

Appointment Details & Preferences

Preferred Appointment Type: In-person    Telehealth

Preferred Days / Times: Mon Tue Wed Thu Fri    Morning Afternoon Evening

Consent for Treatment

I hereby consent to routine medical care and treatment as deemed necessary by the treating clinician(s) during this reappointment and any ancillary services authorized by the practice. I understand that the nature and purpose of recommended services will be explained to me and that I may ask questions prior to treatment. I acknowledge that the practice will obtain separate informed consent for procedures with significant risks or that are invasive in nature.

Acknowledgement of Consent: I acknowledge and consent to receive medical care as described above.

HIPAA Privacy & Communication Preferences

I acknowledge receipt of the practice's Notice of Privacy Practices, which explains how my medical information may be used and disclosed. I understand my rights regarding access to and amendment of my health information, and the procedures to file a complaint.

Acknowledgement: I acknowledge that I have received and reviewed the Notice of Privacy Practices.

Authorization to Leave Messages: Leave voicemail at primary phone    Send text reminders to primary phone    Email communications to email address on file

Authorization to Release Records

I authorize the release of my medical records related to treatment, billing, and appointment scheduling to the individuals or entities listed above or as required for continuity of care and payment. This authorization does not permit release of psychotherapy notes except where expressly indicated in writing.

Expires: / /

I understand that I may revoke this authorization at any time in writing, except for disclosures already made in reliance on this authorization. Revocation must be submitted to the practice's medical records department.

Patient Certification

By signing below, I certify that the information provided in this packet is true and complete to the best of my knowledge. I agree to notify the practice promptly of any changes to my information, medical condition, or insurance coverage. I understand that I remain financially responsible for services rendered and that accurate insurance information is necessary for billing.

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