Healthcare Welcome Package

HEALTHCARE WELCOME PACKAGE

This Healthcare Welcome Package collects necessary administrative, medical and authorization information to establish care, obtain insurance benefits, and document informed consent for treatment. Please complete all sections legibly. By signing at the end of this document you confirm that the information provided is true and that you consent to the terms, notices, and authorizations contained herein.

Patient Information

Date of Birth:    Gender:

Primary Phone:    Secondary Phone:    Email:

Emergency Contact

Relationship:    Phone:

Insurance & Billing Information

Policy / ID Number:    Group Number:

Subscriber Date of Birth:    Insurance Phone:

Medical History

Primary Care Provider:    Preferred Pharmacy:

Consent for Treatment

I authorize the medical staff of this practice to provide evaluation, diagnostic procedures, and treatment as deemed necessary for my care. I understand that no guarantees have been made as to the results of examinations or treatments. I acknowledge that risks, benefits, and alternatives to recommended treatments have been explained to me, and I have had an opportunity to ask questions.

Procedure / Service to be provided (describe or enter general care type):

I consent to routine diagnostic procedures and any related ancillary services required for my care. I understand I may withdraw consent at any time by providing written notice, except to the extent that action has already been taken in reliance on this consent.

Consent to Treatment: I give informed consent for treatment and related services as described above.

Authorization to Release Medical Information

I authorize the release of my protected health information to entities involved in my care, billing, and quality review. This may include information related to diagnosis, treatment, medication, laboratory results, and billing records. This authorization permits disclosure both verbally and in written form.

This authorization expires on: . I understand I may revoke this authorization in writing at any time, except to the extent that action has been taken in reliance on this authorization.

Financial Responsibility & Assignment of Benefits

I understand that I am financially responsible for all charges whether or not covered by insurance. I authorize assignment of benefits to the provider for claims submitted on my behalf. I agree to promptly pay any copayments, deductibles, or amounts not paid by my insurer.

Responsible Party (if other than patient):

HIPAA Privacy Practices Acknowledgment

I acknowledge receipt of the Notice of Privacy Practices that explains how my medical information may be used and disclosed and how I can obtain access to this information. I understand that the notice is available upon request and that this acknowledgement is not a form of authorization for disclosure beyond treatment, payment, and healthcare operations unless separately authorized.

Acknowledgement of Receipt: I acknowledge that I have received or been offered the practice's Notice of Privacy Practices.

Communications & Telehealth

I consent to communications regarding appointments, billing, and treatment by telephone, voicemail, text message, and email to the contact information provided above. I understand telehealth visits may be offered and I consent to the use of telehealth for evaluation and treatment where clinically appropriate.

Consent to Electronic Communications: I consent to receive electronic communications as described above.

Patient Rights & Complaints

Patients have the right to be treated with dignity and respect, to receive information about their care, and to file a complaint if they believe their rights have been violated. Complaints may be submitted in writing to practice management; complaints will be addressed according to applicable policies and laws.

Optional Authorizations

Release appointment reminders to:    Relationship:

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