Healthcare Submission Form

Healthcare Submission Form

Patient Information

Date of Birth:    Gender: Male Female Other Prefer not to say

Emergency Contact

Insurance Information

Subscriber Date of Birth:

Medical History

Primary Care Physician:    Date of last physical:

Smoking/Tobacco Use: Yes No    Alcohol Use: Yes No    Recreational Drug Use: Yes No

Consent for Evaluation and Treatment

I hereby authorize the facility and its health care providers to provide evaluation, diagnostic testing, and treatment as deemed necessary for my care. I understand that treatment may include invasive and non-invasive procedures, administration of medications, and other medically indicated interventions. I acknowledge that no guarantees have been made as to the results of any treatments.

Risks, potential complications, and expected benefits of recommended procedures and treatments have been explained to me to the extent reasonably possible in the clinical setting. I understand I have the right to ask questions and to refuse or withdraw consent at any time before treatment is provided, except when immediate care is required for emergency medical reasons.

I consent to evaluation and treatment by the facility and authorized providers. I decline to give consent at this time.

HIPAA Privacy Acknowledgment & Authorization

I acknowledge that I have received or been offered the facility's Notice of Privacy Practices describing how my protected health information may be used and disclosed for treatment, payment, and health care operations. I understand that I have the right to request restrictions on certain uses and disclosures and to revoke this authorization in writing, except to the extent that action has already been taken in reliance on this authorization.

Patient authorization for use and disclosure for treatment and billing purposes: I authorize use and disclosure of my information for treatment, payment, and healthcare operations.

Release to family/emergency contact: Permit disclosure to emergency contact listed above regarding my care Do not disclose medical information to family/emergency contact

Authorization to Release Medical Records

I authorize the release of my protected health information to the recipient identified below for the purpose specified. This authorization includes records related to mental health, substance use treatment, and communicable diseases only if I have indicated so in the special authorizations section below.

Authorization Expiration Date:    If left blank, this authorization will expire one year from the date signed unless a different period is required by law.

Special authorizations (check to include): Mental health records Substance use treatment records HIV-related information

Affirmations and Certifications

By signing below I certify under penalty of law that the information provided on this form is true and complete to the best of my knowledge. I authorize the release of information necessary to process claims and to provide continuity of care. I understand that I may revoke this authorization in writing at any time except to the extent that the organization has already acted in reliance on it.

I understand that if I refuse to sign or later revoke this authorization, services may be limited except where prohibited by law. I understand that re-disclosure by the recipient may no longer be protected by privacy regulations.

I affirm that the information provided herein is accurate and that I have read and understand the statements above.

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