Healthcare Service Information Form

HEALTHCARE SERVICE INFORMATION FORM

Please complete this form in full. The information you provide will be used to plan and document clinical services, verify insurance coverage, and ensure safe and appropriate care. By signing this form you certify that the information is true and complete to the best of your knowledge and acknowledge the privacy and billing statements contained herein.

Patient Information

Date of birth:    Gender: Male Female Other Prefer not to say

Preferred language for clinical communication:    Interpreter required: Yes No

Mobility assistance required (wheelchair, walker, escort): Yes No    If yes, describe:

Emergency Contact

Insurance Information

Subscriber date of birth:

Medical History

Service Details

Reason for visit / chief complaint:

Date of service:    Referring clinician:

Consents, Authorizations and Acknowledgements

Consent to treatment: I authorize clinicians and staff to provide medically necessary evaluation and treatment for the condition(s) described above. I understand that no treatment is without risk and that common risks and expected benefits will be explained prior to procedures when applicable. I have the right to ask questions and to withdraw consent at any time except where withdrawal would jeopardize the safety of my care.

Financial responsibility: I am financially responsible for services rendered that are not covered or are denied by my insurance carrier, including co-payments, deductibles, and non-covered services. I authorize use of this information to bill my insurance and for payment to be made directly to the provider when applicable.

Release of information: I authorize release of medical information necessary for treatment, payment, and health care operations. This authorization includes release to insurers and other health care providers involved in my care, and does not authorize release for other purposes unless required by law or separately authorized.

HIPAA acknowledgement: I acknowledge receipt of the facility's Notice of Privacy Practices that describes how protected health information may be used and disclosed. I understand that I may request restrictions on certain uses and disclosures and that requests will be considered in accordance with law and facility policy.

Authorization expiration: This authorization to use and disclose information and to bill insurance shall remain in effect until:    If no date is provided, authorization will remain effective for the period necessary for treatment and billing unless revoked in writing.

Emergency contact permission: In the event of an emergency, the facility may contact the emergency contact listed above and provide clinical information necessary for immediate care.    Release for appointment reminders and test results: Yes No

Additional Notes

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