Healthcare Services Declaration

HEALTHCARE SERVICES DECLARATION

Provider Name:    Facility Location:

Patient Information

Date of Birth:    Gender: Male Female Other

Emergency Contact

Insurance Information

Medical History

Description of Proposed Services

I acknowledge that the services to be provided are described as follows:

Estimated duration or number of visits:    Estimated charges (if provided): $

Risks, Benefits, and Alternatives — Acknowledgment

I understand that all treatments and procedures involve risks and benefits. The proposed services, the significant risks, the anticipated benefits, and reasonable alternatives (including no treatment) have been explained to me. I have had the opportunity to ask questions and to receive answers that I understand.

By checking the box below I acknowledge receipt of that explanation and my opportunity to ask questions:
I acknowledge that risks, benefits, and alternatives were explained to me and that I understand them.

Consent to Treatment; Right to Withdraw

I voluntarily consent to the administration of the services described above and to any additional procedures that are necessary or advisable in the reasonable medical judgment of the treating clinicians. I understand that I may refuse or withdraw consent at any time prior to the performance of a procedure, subject to clinical limitations or emergency circumstances.

I consent to the proposed treatment and related services and acknowledge my right to withdraw consent as described above.

Financial Responsibility and Assignment of Benefits

I accept financial responsibility for services rendered by the Provider and agree to pay amounts not covered by my insurer, including deductibles, co-payments, co-insurance and services denied by my insurer. If payment is sought from me, I agree to pay promptly under the Provider's billing policies.

I authorize the Provider to bill my insurance and to request and receive payment directly from the insurer for services rendered. I authorize the release of medical and billing information to my insurer as necessary to process claims. This authorization is a condition of treatment when assignment of benefits is requested.

I authorize assignment of benefits to the Provider and permit direct payment to the Provider for insurance-covered services.

Authorization to Release Medical Information

I hereby authorize the Provider to disclose protected health information to other health care providers, my insurer, and other entities as necessary for treatment, payment, and health care operations. Such disclosures shall be limited to the minimum necessary information required to accomplish the intended purpose.

This authorization will expire on: unless earlier revoked in writing.

I authorize release of medical information as described above.

Privacy Notice Acknowledgment

I acknowledge that I have been offered or received a copy of the Provider's Notice of Privacy Practices describing how my health information may be used and disclosed and my rights regarding that information under applicable privacy law.

I acknowledge receipt of the Notice of Privacy Practices or that it was made available to me.

Certification and Accuracy

I certify that the information I have provided on this Healthcare Services Declaration is true and accurate to the best of my knowledge. I understand that misstating or omitting relevant medical or insurance information may affect my care and my financial responsibility for services rendered.

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