Healthcare Registration Packet

Healthcare Registration Packet

Patient Information

Date of Birth:    Gender: Male   Female   Other

Home Phone:    Mobile Phone:

Emergency Contact

Relationship:    Phone:

Insurance & Billing Information

Policy / ID Number:    Group Number:

Medical History

Diabetes    Hypertension    Heart Disease    Asthma/COPD    None of the above

Do you use tobacco?   Yes   No    Alcohol use?   None   Social   Regular

Consent for Treatment / Financial Agreement

I authorize medical evaluation and treatment as deemed necessary by the provider. I understand that unanticipated complications may occur and that no guarantees have been made concerning the results of treatment or procedures. I have the right to refuse any recommended treatment and to withdraw consent at any time, except when withdrawal would jeopardize my health or safety.

Assignment of Benefits: I hereby assign to the provider all medical benefits payable to me under my insurance policy. I authorize the release of any medical information necessary to process claims and agree to be financially responsible for charges not covered by insurance, including deductibles, co-payments, and any non-covered services.

Payment Responsibility: Payment is due at the time of service unless other arrangements are made in writing. In the event of nonpayment, I understand outstanding balances may be referred for collection and additional fees may be charged.

Consent to communicate: I authorize the clinic to contact me by phone, voicemail, or text message at the numbers provided regarding appointments, billing, and clinical matters. I understand messaging may not be completely secure and I may withdraw this consent in writing.

Authorization for Release of Medical Records

I authorize the release of my medical information to the following person(s)/organization(s) for treatment, payment, or healthcare operations:

I understand that I may revoke this authorization at any time by delivering written notice to the clinic except to the extent that action has already been taken in reliance on this authorization. Re-disclosure by the recipient may no longer be protected by privacy regulations.

HIPAA Privacy Acknowledgment

I acknowledge receipt of the clinic's Notice of Privacy Practices, which explains how my protected health information may be used and disclosed and how I can obtain access to this information. I understand my rights regarding my health information, including the right to request restrictions and confidential communications.

Acknowledgment: I acknowledge that I have received and understand the Notice of Privacy Practices.

Additional Authorizations & Notices

Telehealth: I consent to receive telehealth services when provided. I understand risks and limitations of telehealth and that I may decline telehealth and request in-person care.

Minors and Guardianship: If the patient is a minor or unable to provide informed consent, the undersigned certifies that they are the parent, legal guardian, or legally authorized representative and have authority to consent to care on behalf of the patient.

Patient Certifications

By signing below, I certify under penalty of law that the information provided on this form is true and correct to the best of my knowledge. I authorize treatment, assignment of benefits, and the release of information as indicated above. I understand my financial obligations and my rights with respect to privacy and access to my health information.

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