Healthcare Signup Form

HEALTHCARE SIGNUP FORM

Patient Information

Patient Name:

Female Male Non-binary Other

Emergency Contact

Insurance Information

Primary Insurance Provider:

Medical History

Do you smoke? Yes No Are you currently pregnant? Yes No

Consent for Treatment and Financial Responsibility

I, the undersigned patient (or legal representative), authorize licensed clinicians and support staff of this facility to provide evaluation, diagnostic procedures, and medically necessary treatment as determined by the treating clinician. I understand that all care will be provided in accordance with accepted clinical standards.

I acknowledge financial responsibility for services provided and agree to pay any applicable co-payments, deductibles and balances not covered by insurance. This includes charges for missed appointments when applicable under facility policy. I authorize payment of benefits to the provider for services rendered when applicable and permit release of necessary information to payers for claims processing.

Authorization to Release Medical Information

By signing below, I authorize the release of my health information as necessary for treatment, payment, and healthcare operations. This authorization includes release to other healthcare providers, payers, and their agents for the purposes of continuing care and claims adjudication. I understand that the information disclosed may include sensitive health information, including mental health and substance use treatment, where applicable.

This authorization will remain in effect until: unless revoked earlier in writing. I understand that I may revoke this authorization at any time by providing written notice, except to the extent that action has already been taken in reliance on this authorization.

HIPAA Acknowledgment

I acknowledge receipt of the facility's Notice of Privacy Practices which describes how my health information may be used and disclosed and how I can access this information. I understand my rights regarding protected health information and that the facility will make reasonable efforts to protect my privacy.

Preferred method(s) of contact for appointment reminders and health information: Phone Email SMS/Text

Acknowledgment and Certification

By signing below, I certify that the information I have provided on this form is true and complete to the best of my knowledge. I understand that knowingly providing false information may result in denial of services or termination of care. I consent to the release and exchange of health information as described above.

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