Healthcare Service Policy

HEALTHCARE SERVICE POLICY

Patient Information

Patient Name:

Date of Birth:    Gender:

Primary Phone:    Email:

Relation:    Phone:

Insurance & Billing

Policy/ID Number:    Group Number:

By initialing here, I authorize release of necessary medical information to my insurer for claims processing and understand I am financially responsible for charges not covered by insurance. Initials:

Medical History (Required)

Appointments, Cancellations & No-Show Policy

Appointments are scheduled to minimize waiting times. Patient agrees to provide reasonable notice for cancellations. A cancellation made less than 24 hours before the scheduled appointment may incur a cancellation fee equal to the standard visit charge or a fixed fee as established by the practice.

Patient acknowledges and accepts responsibility for payment of late cancellation or no-show fees not reimbursed by insurance. Initials:

Privacy, Records & Release of Information

Patient acknowledges receipt of the practice's Notice of Privacy Practices and understands the practice's obligations regarding protected health information. Patient grants permission to communicate appointment reminders and health information via telephone, voicemail, and electronic messaging unless otherwise restricted in writing.

I authorize the release of my medical records, including billing information, to the following persons or entities:

This authorization to release information shall remain in effect until: . Patient may revoke this authorization in writing except to the extent action has been taken in reliance on it.

Consent to Treatment & Service Terms

I consent to customary diagnostic and therapeutic procedures, treatment by clinical staff, and any ancillary services determined to be necessary by my treating clinician. I understand risks and benefits of proposed care will be explained upon request or as reasonably practicable prior to treatment.

I understand that medical care cannot be guaranteed. I have the right to ask questions, obtain explanations, and refuse or withdraw consent for treatment at any time, except where refusal would jeopardize the life or health of the patient or others.

For minors or patients under legal guardianship, the signer certifies they have the legal authority to consent to treatment on behalf of the patient. Relationship to patient must be indicated in the signature block.

Financial Responsibility & Collections

Patient is responsible for all charges for services rendered. The practice may submit claims to insurance as a courtesy; however, ultimate responsibility for payment remains with the patient. Unpaid balances may be referred to an outside collection agency if not resolved after reasonable notice.

By signing below, patient acknowledges responsibility for co-payments, deductibles, and services not covered by insurance, and consents to the release of billing information to third-party payors as necessary for payment.

Acknowledgment & Certification

I certify that the information I have provided in this Healthcare Service Policy is true and accurate to the best of my knowledge. I have read, understand, and accept the terms, conditions, and policies set forth in this document, including financial responsibility, appointment and cancellation policies, and privacy practices.

I authorize the exchange of health information necessary for treatment, payment, and health care operations consistent with applicable law and the practice's privacy policies.

If signing on behalf of the patient, I attest that I am the parent, legal guardian, or authorized representative and have the legal authority to execute this document.

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