Healthcare Specialist Document

Healthcare Specialist Document

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Other

Emergency Contact

Insurance Information

Referral / Consultation Details

Medical History

Consent for Consultation and Treatment

I, , authorize the specialist named above to provide consultation and recommended diagnostic or therapeutic services related to the reason for referral. I understand that:

1. The specialist will explain the nature of recommended services, expected benefits, reasonably foreseeable risks, and material alternatives. I have the right to ask questions and receive explanations in language I understand.

2. Risks may include, depending on the procedure, but are not limited to infection, bleeding, allergic reaction, failure to achieve desired outcome, and unforeseen complications. I acknowledge that no guarantee has been made as to the result of any treatment.

3. I may refuse or withdraw consent at any time prior to the initiation of a procedure by communicating that decision to the specialist or treating staff. Withdrawal of consent will be documented and does not affect care already rendered.

Please indicate consent where indicated below:

I consent to consultation and recommended diagnostic evaluation.

I consent to receive treatment recommended by the specialist, including routine measures deemed necessary in the course of care.

Authorization for Release of Medical Information

I hereby authorize release of my medical records, diagnostic images, lab results, and pertinent clinical information from the referring provider and any treating providers to the specialist listed in this form and vice versa as necessary for treatment, care coordination, and payment. This authorization includes disclosure of substance abuse, mental health, and HIV-related information where relevant to care.

I understand that I may revoke this authorization at any time by submitting a written revocation to the releasing provider, except to the extent that action has already been taken in reliance on this authorization. Unless revoked earlier, this authorization will expire on the date specified above or, if no date is provided, one year from the date of signature.

Billing, Assignment and Financial Responsibility

I authorize the specialist and associated providers to bill my health plan and to release information necessary to process claims. I assign benefits to the specialist for payment of services rendered. I accept responsibility for charges not covered or paid by my insurer, including deductible, copayment, and coinsurance amounts, as permitted by applicable law and my insurance contract.

HIPAA Privacy Acknowledgment

I acknowledge that I have been offered a copy of the Notice of Privacy Practices describing how my health information may be used and disclosed and how I may obtain access to this information. I understand that the specialist may use and disclose my protected health information for treatment, payment, and health care operations as described in that notice.

I acknowledge receipt of the Notice of Privacy Practices or waive receiving a copy at this time.

Additional Authorizations / Instructions

By signing below I certify that I have read and understand this Healthcare Specialist Document, that the information I provided is true and correct to the best of my knowledge, and that I am authorized to provide the consents and authorizations contained herein. A copy or electronic reproduction of this signed document shall be considered as valid as the original.

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