Healthcare Unified Agreement

Healthcare Unified Agreement

Patient Information

Insurance Information

I hereby authorize the release of any medical or other information necessary to process insurance claims and to coordinate care with other health care providers. I authorize payment of medical benefits to the treating provider unless otherwise indicated in writing.

Medical History

Consent for Treatment

I authorize the health care provider and such assistants as the provider may designate to perform medical examinations, diagnostic tests, procedures, and treatments as deemed necessary for my care. I acknowledge that no guarantee has been made as to the results of any treatment.

I have been informed of the nature and purpose of the proposed treatment, the anticipated benefits, the material risks and adverse effects, reasonable alternatives (including no treatment), and the likely consequences of not receiving treatment. I understand that complications can occur, including but not limited to infection, bleeding, allergic reaction, or other unforeseen outcomes.

I acknowledge that I have the right to ask questions and to withdraw my consent at any time prior to the procedure without affecting my right to future care or treatment.

Authorization to Release Health Information (HIPAA)

I authorize the disclosure of my protected health information to the persons and entities necessary for treatment, payment, and health care operations. This authorization includes release of records to insurers, referring providers, and other treating providers. I understand that information disclosed pursuant to this authorization may include behavioral health and substance use treatment information unless I indicate otherwise below.

Authorization to disclose records to specific individuals: Name: Relationship:

This authorization is effective as of: and shall expire on: unless earlier revoked in writing.

Financial Responsibility and Assignment of Benefits

I accept financial responsibility for charges not covered by insurance, including deductibles, co-payments, co-insurance, and services denied by my insurer. I authorize payment of insurance benefits directly to the provider for services rendered. I understand that billing statements may be sent to the address on file and that unpaid balances may be subject to collection actions consistent with applicable law.

Patient Acknowledgments

By signing below, I certify that the information provided in this document is true and complete to the best of my knowledge. I grant permission for the health care provider to proceed with treatment as described and to communicate with other providers and insurers as necessary for my care and billing.

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