Healthcare Signatures

HEALTHCARE SIGNATURES

Patient Information

Date of Birth:    Gender:    SSN (last 4 digits):

Primary Phone:    Alternate Phone:

Relationship:    Phone:

Insurance Information

Policy Number:    Group Number:    Subscriber Name:

Medical History

Primary Care Physician:

Consent to Treatment and Acknowledgments

I, the undersigned patient (or authorized representative), authorize the healthcare providers and staff to provide medical evaluation, diagnostic procedures, treatment, and other services as deemed necessary. I acknowledge that no guarantee has been made as to the results of examinations or treatments.

Procedure / Treatment Description (if applicable):

I have been informed of the nature and purpose of the proposed treatment, the reasonably foreseeable risks and benefits, and available alternatives including no treatment. I understand I may withdraw consent at any time prior to or during treatment, except where withdrawal may jeopardize my health or where procedures have already commenced.

Consent selections (check those that apply):

I consent to general medical treatment and routine procedures.
I consent to the specific procedure(s) described above.
I consent to clinical photography or videography for treatment, documentation, and education, with understanding that identifying information will be protected.
I consent to telemedicine/remote consultations when recommended by my provider.

Authorization to Use and Disclose Health Information (HIPAA)

I acknowledge receipt of the Notice of Privacy Practices and understand my rights regarding protected health information. By signing below I authorize the release of my protected health information as described in the selections below.

Acknowledgments and permissions:

I acknowledge I have received or been offered the facility's Notice of Privacy Practices.
I authorize disclosure of health information to other healthcare providers for treatment, payment, or healthcare operations.
I authorize release of my records to the party named below for the purpose stated.

To include specific sensitive information, check to authorize release of the categories below (check only if you authorize):

HIV/AIDS-related records
Mental health records (psychotherapy notes excluded unless specified)
Substance use disorder records

This authorization will expire on:    If left blank, this authorization will expire one year from the date signed.

Communications Preferences

I authorize the facility to contact me by the following means for appointment reminders, test results, and billing communications:

Phone call to primary number
Voicemail messages at my phone number
SMS / text message to primary number
Email to address provided

Patient Certification and Attestation

By signing below I certify that the information I have provided is true and complete to the best of my knowledge. I understand that falsification or omission of material information may affect the care I receive and may have legal consequences. I understand my rights to refuse or revoke consents set forth above by delivering written notice to the facility, except to the extent action has already been taken in reliance on this authorization.

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