Healthcare Signature Documents

HEALTHCARE SIGNATURE DOCUMENTS

Patient Information

Patient Name:

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History

Consent for Treatment

I, the undersigned, consent to examination, diagnostic procedures, and medical or surgical treatment as may be recommended by clinical staff and physicians. I acknowledge that no guarantee can be made as to the results of treatment. I understand the nature, anticipated benefits and material risks of proposed care and alternatives, including the option of no treatment where applicable.

Purpose and Description of Proposed Treatment or Procedure:

By checking the boxes below I expressly acknowledge the following statements:

I have been informed of the significant risks, benefits, and alternatives and understand them.

I understand I may withdraw this consent at any time before the procedure by notifying the provider, except to the extent action has already been taken in reliance on my consent.

Authorization to Release Medical Information (HIPAA Authorization)

I authorize the release and disclosure of my protected health information as described below. This authorization is voluntary and I understand that I may revoke it in writing at any time, except to the extent that disclosures have already been made in reliance on this authorization.

Expiration of Authorization:

Purpose:

I understand that information disclosed pursuant to this authorization may include records related to mental health treatment, substance use disorder treatment, communicable diseases, or other sensitive information unless expressly excluded here:

Assignment of Benefits and Financial Responsibility

I assign to the treating provider all rights to insurance benefits for services rendered and authorize payment of benefits directly to the provider. I accept financial responsibility for charges not covered by insurance, including co-payments, deductibles, and services deemed non-covered.

I authorize payment of insurance benefits to the provider and accept financial responsibility as stated above.

Patient Acknowledgments

By signing below I acknowledge the following:

I have received or been offered a copy of the provider's Notice of Privacy Practices and understand my rights regarding my health information.

I have had the opportunity to ask questions and my questions have been answered to my satisfaction.

Optional Notices and Limits

If you do not wish to authorize release of any portion of your records, list specific limits here:

Sign Now