Healthcare Service Options

HEALTHCARE SERVICE OPTIONS

This Healthcare Service Options form documents the services the patient elects to receive, authorizes the use and disclosure of health information necessary for treatment, payment, and healthcare operations related to the selected services, and acknowledges the patient’s responsibilities for payment. Please complete all sections fully and sign at the end to confirm selection and authorization.

Patient Information

Date of Birth:    Gender: Male Female Other (specify):

Insurance Information

Assignment of Benefits: I authorize the assignment of benefits and direct payment to the provider for covered services. Initials:

Service Options (Select all that apply)

Primary Care

Specialist Referral — If selected, specify specialty:

Telehealth Consultation

Behavioral Health / Mental Health Services

Laboratory Testing — Tests to be ordered:

Diagnostic Imaging (X‑ray, MRI, CT) — Indicate study:

Medication Management / Prescription Services

Home Health Services

Palliative / Hospice Care

Physical Therapy / Rehabilitation

Preventive Services / Vaccination — If vaccination, specify:

Care Coordination / Case Management

Other:

Medical History

Consent, Authorization, and Financial Responsibility

By selecting the services above and signing below, I, the patient or authorized representative, hereby:

1. Authorize the provision of the selected healthcare services and any routine ancillary services necessary for diagnosis or treatment; I understand that specific procedures may require separate informed consent.

2. Acknowledge that treatments and procedures have potential benefits, risks, and alternatives; I have the right to ask questions and to refuse or withdraw consent at any time, except as limited by law.

3. Authorize release of medical information as necessary for treatment, payment, and healthcare operations to other providers, facilities, laboratories, and payers involved in my care. I understand that certain disclosures may include records related to behavioral health, substance use treatment, or other sensitive information as required for care and billing.

4. Agree to be financially responsible for charges not covered by my insurer, including co‑payments, deductibles, and services denied by my insurer. I acknowledge that prior authorization by my insurer does not guarantee payment and that I remain responsible for unpaid balances.

5. I may revoke this authorization at any time in writing, except to the extent that action has been taken in reliance on it. Revocation does not affect disclosures already made pursuant to this authorization.

Release to Emergency Contact: I authorize release of relevant health information to the emergency contact named above.

Authorization Expiration Date: (If left blank, authorization expires one year from signature date unless otherwise required by law.)

Privacy and Acknowledgements

Acknowledgement of Privacy Practices: I acknowledge receipt of the provider’s Notice of Privacy Practices and understand my rights regarding my health information.

Communications Preference: I prefer to be contacted about appointments and health information by: Phone Email Mail

Confidential Contacts (additional persons authorized to receive information): Name: Relationship:

Certification

By signing below I certify that I am the patient or legally authorized representative and that the information provided on this form is true and complete to the best of my knowledge. I have read and understand the terms above and authorize the selected healthcare services and associated disclosures as specified.

If signed by an authorized representative, state relationship to patient:

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