Healthcare Signature Document

HEALTHCARE SIGNATURE DOCUMENT

Patient Information

Patient Name:

Insurance Information

Medical History

Authorization for Use and Disclosure of Protected Health Information (PHI)

I hereby authorize the following disclosure:

Purpose of Disclosure (check all that apply):

Treatment & continuity of care    Billing, claims, payment    Legal proceedings    Other (specify):

I authorize release of the following records (select specific categories or select All Records):

All medical records    Laboratory results    Imaging reports (X-ray, CT, MRI)    Progress notes & clinical summaries    Billing statements

Specific dates of service to be disclosed: From to

I understand that information disclosed pursuant to this authorization may include records and information pertaining to mental health treatment, communicable diseases including HIV/AIDS, and substance use disorder treatment. I specifically authorize release of such information by initialing here:

This authorization will expire on (enter date) or upon the following event/condition:

I understand I may revoke this authorization in writing at any time except to the extent action has already been taken in reliance upon it. To revoke, I must submit a written statement to the disclosing provider identified above. I understand that revocation will not affect disclosures already made in reliance on this authorization prior to receipt of the revocation.

Consent to Treatment & Acknowledgments

Consent to Treatment: I consent to medical treatment, diagnostic procedures, and nursing care as deemed necessary by the provider or facility named above. I acknowledge that no guarantees have been made regarding the results of any treatment or procedure.

Acknowledgment of Privacy Practices: By signing below I acknowledge that I have been offered a copy of the provider's Notice of Privacy Practices, which explains how my health information may be used and disclosed and how I can obtain access to my information. I understand my rights as described in that Notice.

Certification: I certify that the information I have provided on this form is true and correct to the best of my knowledge. I understand that intentionally providing false information may result in denial of services, billing disputes, and may be subject to applicable penalties under law.

Patient Authorization

By signing below, I authorize the release of my protected health information as specified above and consent to the treatment described. I understand my rights and that I may refuse to sign this authorization without affecting my ability to obtain treatment, except where disclosure is necessary for the provision of health care or if the program has specific legal requirements.

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