Healthcare Templates

Patient Intake, Consent & HIPAA Authorization

Patient Information

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Subscriber Date of Birth:

Medical History

Consent for Treatment

I, the undersigned, authorize the medical providers and staff of this practice to perform routine diagnostic and therapeutic procedures as deemed necessary for my care, including but not limited to examinations, injections, minor procedures, and diagnostic testing. I acknowledge that the nature of the proposed treatment has been explained to me and that no guarantee has been made as to the results. Procedure(s) to be performed:

Risks and potential complications may include infection, bleeding, allergic reaction, scarring, persistent pain, failure to achieve desired result, and other risks reasonably associated with the procedure. Benefits and expected outcomes have been explained to me and I have had the opportunity to ask questions.

Right to Withdraw / Revocation

I understand that I may revoke this consent at any time in writing, except to the extent that action has already been taken in reliance upon this consent. Revocation will not affect any disclosures or actions taken prior to receipt of the revocation.

HIPAA Authorization & Privacy Acknowledgment

I authorize the disclosure of my protected health information as necessary for treatment, payment, and healthcare operations. I understand that information disclosed pursuant to this authorization may include medical records, test results, and billing information. I understand that I may refuse to sign this authorization and that treatment will not be conditioned upon signing, except where allowed by law.

Expiration: This authorization will expire on unless earlier revoked in writing or as required by law.

Patient Rights Acknowledgment

I acknowledge receipt of the Notice of Privacy Practices, which explains how my health information may be used and disclosed, and my rights concerning that information. I understand I may request a paper copy of the notice.

Certification: By signing below I certify that the information provided on this form is accurate to the best of my knowledge, that I consent to the treatment described above, and that I authorize the release of my health information as indicated. I understand that falsification of information may be grounds for refusal or termination of care.

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