Healthcare Requirements List

HEALTHCARE REQUIREMENTS LIST

Purpose: This Healthcare Requirements List documents required preparations, items to bring, and administrative prerequisites for the patient’s upcoming appointment or procedure. Patient must review each item, indicate compliance where requested, and sign the acknowledgment at the end. Failure to satisfy listed requirements may result in delay or cancellation of services and may affect coverage by the patient’s insurer.

Patient Information

Date of Birth:    Gender:

Insurance & Administrative

Pre-authorization obtained: Yes    Insurance card photocopy provided: Yes    Photo ID presented: Yes

Medical History & Medications

Procedure & Pre-Procedure Requirements

Appointment/Procedure Date:    Arrival Time:

Fasting requirement (NPO): hours prior to arrival. Last solid food: , Last clear liquid:

Medication instructions provided: Acknowledged    Specific medication hold instructions (if any):

Patient has been advised of risks of noncompliance (missed fasting, failure to stop medications, failure to bring ID/insurance): Yes

Logistics & Support Needs

Transportation required after procedure: Yes    Transportation arranged: Yes

Interpreter required: Yes    Preferred language:

Mobility assistance required (wheelchair/walker): Yes

Photo ID    Insurance card    List of medications

Infectious Disease Screening

Within 14 days prior to the appointment, have you experienced any of the following symptoms? (check all that apply)

Fever or chills    New cough    Shortness of breath

Recent known exposure to a communicable disease: Yes    If yes, date of exposure:

Authorizations, Acknowledgements & Notices

Authorization to release information: By signing below, the patient authorizes the release of medical and billing information necessary for treatment, payment, and healthcare operations to the patient’s insurer and as otherwise permitted by law. This authorization does not extend to psychotherapy notes unless separately authorized.

Acknowledgement of requirements: The patient certifies that they have been informed of the clinical, administrative, and logistic requirements set forth in this document, that they understand the potential consequences of noncompliance (including delay, rescheduling or denial of the service), and that they will follow the listed instructions unless otherwise instructed in writing by the treating clinician.

HIPAA Privacy Acknowledgement: The patient acknowledges receipt of the facility’s Notice of Privacy Practices and consents to the use and disclosure of protected health information for treatment, payment, and healthcare operations as described in that notice to the extent permitted by law.

Right to withdraw: The patient understands they may withdraw consent or decline to follow any non-emergent requirement prior to the start of the procedure; however, withdrawal or refusal may result in cancellation or postponement of care.

Authorization expiration date (authorization to release medical information under this document and to proceed with administrative requirements):

I authorize the facility to contact my emergency contact or legal representative if needed: Yes

Patient Certification

By signing below I certify under penalty of perjury that the information provided on this Healthcare Requirements List is true and complete to the best of my knowledge, that I have received and understand the instructions and requirements contained herein, and that I consent to the uses and disclosures described above.

If signed by authorized representative, indicate relationship to patient:

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