Healthcare Starter Kit Document

HEALTHCARE STARTER KIT DOCUMENT

Patient Information

Patient Name:

Date of Birth:    Gender: Female Male Other

Emergency Contact

Insurance Information

Medical History

Primary Care Physician:    Phone:

Are you pregnant, planning pregnancy, or breastfeeding?   Yes No

Consent for Treatment

I hereby authorize and consent to routine diagnostic procedures, examinations, and medical treatment as ordered by the treating provider. I understand that medical care involves risks and that no guarantee has been made as to the results of any treatments or procedures. I acknowledge I may withhold or withdraw consent at any time except when withdrawal could endanger my health or safety or as otherwise provided by law.

I consent to the administration of medications, vaccinations, and minor procedures as clinically indicated: I consent    I decline

Authorization to Release Medical Records

I authorize the release of my protected health information to the following recipient for the purpose indicated. I understand that information disclosed pursuant to this authorization may include records related to behavioral health, substance use treatment, HIV/AIDS, and other sensitive information unless specifically excluded below.

Purpose of Disclosure:

This authorization will expire on: . I understand I may revoke this authorization in writing except to the extent the action has already been taken in reliance upon it.

Financial Responsibility & Assignment of Benefits

I agree to be financially responsible for services rendered. I authorize payment of benefits directly to the provider for covered services and understand I remain responsible for amounts not covered by insurance, including copayments, deductibles, and non-covered services. I understand that failure to pay may result in collection activity.

Assignment of Benefits: I authorize assignment    I do not authorize assignment

HIPAA Privacy Acknowledgment & Communications Preference

I acknowledge that I have been offered or received a copy of the Notice of Privacy Practices describing how my health information may be used and disclosed and my rights regarding that information. My signature below constitutes my acknowledgment of receipt or refusal to accept the notice.

May we leave appointment reminders or test results on your voicemail or with another person at your phone number?   Yes No

Patient Rights & Complaint Notice

You have the right to request restrictions on certain uses and disclosures of your protected health information and to inspect and copy your medical record as provided by law. Complaints about privacy practices or any aspect of care may be submitted in writing to the provider; filing a complaint will not affect treatment.

Acknowledgment & 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 authorize the release of information and assignment of benefits as indicated. I understand that any intentionally false statements may be subject to penalties under applicable law.

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