Healthcare Walk-In Document

HEALTHCARE WALK-IN FORM

Patient Information

Patient Name:

Month: Day: Year:

Visit Details

Visit Date: Month Day Year

Insurance Information

Month: Day: Year:

Medical History

Consent and Authorizations

By signing below I authorize medical evaluation and treatment as deemed necessary by the attending clinician. I understand that risks and benefits will be explained and that I may refuse specific treatments at any time. I certify that the information provided on this form is true and complete to the best of my knowledge.

I consent to examination, diagnostic testing, and treatment by clinical staff.

I authorize release of medical information necessary for billing and payment, and assign benefits to the provider.

I consent to the release of relevant medical records to referring providers or other treating facilities for continuity of care.

This authorization will expire on: Month Day Year

Privacy Acknowledgment (HIPAA)

I acknowledge receipt of the provider's Notice of Privacy Practices describing uses and disclosures of my protected health information, my rights with respect to that information, and the provider's duties. I understand that I may request restrictions on certain uses or disclosures, and that such requests will be considered in accordance with applicable law.

I acknowledge that I have received or been offered the Notice of Privacy Practices.

Minor / Guardian Information (if applicable)

Is the patient a minor?

By signing this form I certify that I am authorized to consent to medical treatment for the patient named above if the patient is a minor or otherwise unable to consent.

Attestation

I understand that I am financially responsible for any services not covered or paid by my insurance and that I may be billed for copayments, coinsurance, deductibles, and non-covered services. I agree to pay all charges for services rendered that are not paid or payable by my insurer.

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