Healthcare Well Application

HEALTHCARE WELL APPLICATION

Patient Information

Patient Name:

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History

Do you use tobacco products?   Yes   No

Program Enrollment

Select program services for which you are applying (check all that apply):

Wellness Coaching   Nutrition Counseling   Stress Management   Physical Therapy   Other:

Consent for Participation

By signing this application I authorize enrollment in the selected Healthcare Well program services and consent to receive non-emergency assessment, education, coaching, and treatment as appropriate to the services selected. I understand that program staff may include licensed clinicians, allied health professionals, and authorized support personnel.

I acknowledge that program participation is voluntary and that I may withdraw consent at any time by providing written notice to Program Administration. I understand that withdrawal of consent may affect my continued participation in program services.

I understand potential benefits include improved health status, education and coordination of care. I acknowledge potential risks may include emotional discomfort, unexpected findings that require medical follow-up, and the limitations of remote or non-invasive interventions. I have had the opportunity to ask questions and have received answers to my satisfaction.

Patient consents to routine clinical documentation. I authorize program staff to contact my listed emergency contact and primary healthcare provider for coordination of care as needed. I authorize program staff to discuss relevant health information with the following person(s):

Authorization to Use and Disclose Protected Health Information (PHI)

I authorize the use and disclosure of my protected health information created or received in connection with enrollment and participation in the Healthcare Well program for purposes of treatment, care coordination, payment, and program operations. This authorization includes disclosure to other health care providers, payers, and program contractors as necessary for my care and program administration.

I understand that information disclosed pursuant to this authorization may include information relating to mental health treatment, substance use disorder treatment, HIV status, and other sensitive health information. I understand that I may revoke this authorization at any time by submitting written notice to Program Administration; however, revocation will not apply to information already used or disclosed in reliance on this authorization prior to receipt of the revocation.

I authorize billing of services to my insurance carrier when applicable and understand I am responsible for co-payments, deductibles, and any non-covered services. I certify that the information I have provided on this application is true and correct to the best of my knowledge and that any intentional misrepresentation may result in denial of services.

I acknowledge receipt of the program privacy notice and understand my rights under applicable privacy regulations, including the right to request restrictions on certain uses and disclosures and the right to inspect and obtain copies of my health information.

Acknowledgments and Authorizations

I acknowledge that I have read and understand the above statements and consent to participate in the Healthcare Well program.

I authorize release of necessary information to my insurer and other providers for payment and care coordination.

I permit program staff to contact the emergency contact regarding urgent health matters.

Additional Information

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