Healthcare Signature Pages

HEALTHCARE SIGNATURE PAGES

Patient Information

Insurance Information

Medical History (Brief)

Consent for Treatment

I, , hereby authorize the physicians, nurses and such other persons as may be designated by the provider to perform examinations, diagnostic procedures and treatment as are judged necessary or advisable. I acknowledge that no guarantees have been made to me as to the results of treatment.

By initialing below, I acknowledge that the nature, expected benefits, risks, and alternatives of the proposed care have been explained to me and that I have had an opportunity to ask questions and receive answers. Initials:

Authorization to Release Health Information

I authorize the release of my protected health information to the following recipient(s) for the purpose of treatment, payment, or health care operations: .

This authorization includes disclosure of records relating to alcohol and drug abuse, mental health, HIV/AIDS testing and treatment when such records are relevant to the request. I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by federal privacy regulations.

Assignment of Benefits and Financial Responsibility

I assign to the provider all rights and benefits to insurance or other third-party payments for services rendered. I authorize the release of necessary information to secure payment and understand I am financially responsible for services not covered or payable by my insurer.

Patient accepts financial responsibility: Yes

HIPAA Acknowledgment / Privacy Practices

I acknowledge receipt of the Notice of Privacy Practices describing how my protected health information may be used and disclosed by the provider. I understand that I may request a copy of the notice and that the provider may change the notice at any time.

Acknowledgment given: I acknowledge receipt of the Notice of Privacy Practices.

Communications Consent

The provider may contact me for appointment reminders, billing, or other healthcare information at the telephone number and/or email provided. I consent to receiving communications as indicated below and understand that text messages or voicemail may include limited protected health 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, I must submit a written revocation to the health information management department or other designated office of the provider.

Certification and Signature

By signing below I certify that the information provided on these signature pages is true and correct to the best of my knowledge. I authorize the treatment, release of information, and payment assignment indicated above, and I understand the financial obligations set forth herein.

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