Healthcare Signature Package

HEALTHCARE SIGNATURE PACKAGE

Patient Information

Emergency Contact

Insurance Information

Medical History

Consent to Treatment

I, Patient Name: , hereby consent to the provision of diagnostic, therapeutic and medical services, including routine and emergency treatment, by the providers and staff of this practice. I understand that all treatments involve risks and that no guarantee has been made as to the results that may be obtained.

I have had the opportunity to ask questions regarding recommended procedures, reasonable alternatives, and potential risks and complications. I understand I may withdraw this consent at any time prior to treatment by providing written notice, except when withdrawal would jeopardize my health or safety due to the emergent nature of care already in progress.

Consent to treatment: I authorize medically necessary evaluation and treatment as determined by my clinician.

Authorization for Release of Medical Information (HIPAA Authorization)

I authorize the release and disclosure of my protected health information to the persons and organizations specified below for the purposes indicated. This authorization expressly permits disclosure for continuity of care, insurance claims and payment, and such other purposes as I have specified.

Continuity of care
Billing / Insurance Claims
Legal / Administrative
Other (describe below)

I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by privacy laws. I may revoke this authorization at any time by delivering written notice to the practice, except to the extent that action has already been taken in reliance upon this authorization.

Acknowledgement of Privacy Practices

I acknowledge that I have been offered a copy of the practice's Notice of Privacy Practices describing how my protected health information may be used and disclosed and how I can access this information. By checking the box below I acknowledge receipt or offer of the notice.

I acknowledge receipt or offer of the Notice of Privacy Practices.

Electronic Communications & Telehealth Consent

I consent to receive communications related to my care by the methods I indicate below. I understand electronic communications may not be secure and that I may revoke this consent at any time.

Email communications
SMS / Text message communications
Voicemail messages

Telehealth: I consent to the provision of telehealth services when appropriate. I understand the nature of telehealth, the potential benefits and limitations, and I agree to follow instructions provided by the clinician to protect privacy and security.

Assignment of Benefits & Financial Responsibility

I authorize my insurer to pay benefits directly to this practice where applicable. I accept financial responsibility for charges not covered or paid by my insurer. I understand that I will be responsible for deductibles, co-payments and non-covered services.

I authorize assignment of benefits and accept financial responsibility as stated above.

Revocation and Expiration

I understand I may revoke any authorization herein at any time by submitting a signed and dated written notice, except to the extent that the practice has acted in reliance on the authorization. Unless earlier revoked, this Healthcare Signature Package and the authorizations contained herein shall remain in effect until the stated expiration date or until revoked.

Certifications and Notices

By signing below I certify that I have read and understand the statements contained in this Healthcare Signature Package, that the information I have provided is true and correct to the best of my knowledge, and that I am authorized to sign this document for myself or, if signing on behalf of the patient, that I am the patient's legal guardian or authorized personal representative with authority to execute this document.

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