Healthcare Signature Card

HEALTHCARE SIGNATURE CARD

Purpose: This Healthcare Signature Card documents patient identification, insurance and medical background information, and provides the patient's written authorization for treatment, release of information, and assignment of benefits as set forth below. By signing this form the patient certifies that the information provided is accurate to the best of their knowledge and consents to the terms described in the acknowledgments and authorizations.

Patient Information

Patient Name:

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

Insurance Information

Medical History

Authorizations, Acknowledgments and Certifications

Consent for Treatment: I authorize physicians, nurses and other clinical staff to provide medical care and perform diagnostic and therapeutic procedures as may be deemed necessary by my treating provider. I understand that no guarantees have been made to me as to the results of treatment.

Release of Information: I authorize the release of my medical information, including records of treatment, diagnoses, test results and billing information, to my insurance carriers and to other healthcare providers as necessary for treatment, payment and healthcare operations. This authorization includes release of substance abuse, mental health, and HIV-related information where applicable to the extent permitted by law.

Assignment of Benefits: I assign benefits payable for services provided to me to the treating provider and authorize payment directly to that provider. I understand I remain financially responsible for services not covered or paid by insurance.

HIPAA Acknowledgment: I acknowledge that I have been provided with the provider's notice of privacy practices describing how medical information about me may be used and disclosed, and my rights with respect to that information.

Right to Revoke: I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on this authorization. To revoke, submit a written notice to the provider's records department.

Authorization Duration: This authorization is valid until: unless an earlier revocation is submitted in writing.

Additional Consents: I consent to assignment of insurance benefits to the provider as described above. I consent to release of my medical information for treatment, payment and healthcare operations as described above.

Certification

By signing below I certify under penalty of perjury that the information provided on this form is true and complete to the best of my knowledge. I understand that falsification or omission of material information may result in denial of coverage or termination of services.

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