Healthcare Wellness Clinics Form

HEALTHCARE WELLNESS CLINICS FORM

Please complete this form in full prior to receiving services. The information provided will be used to assess health status, obtain informed consent for routine wellness services, bill insurance where applicable, and maintain medical records in accordance with privacy regulations. Incomplete or inaccurate information may affect care and billing.

Patient Information

Date of Birth:

Gender: Male Female Other / Prefer not to say

Emergency Contact

Insurance Information

Subscriber DOB:

Medical History

Chronic Conditions (check all that apply):

Diabetes Hypertension Asthma / COPD Heart disease Other

Smoking status: Current smoker Former smoker Never smoked

Last tetanus or booster date:

Consent for Treatment and Billing Authorization

I authorize Healthcare Wellness Clinics and its authorized clinicians and staff to provide routine wellness evaluation and treatment, including but not limited to physical examination, diagnostic screening tests, immunizations, laboratory specimen collection, and minor procedures as clinically indicated. I understand that all services will be provided in accordance with accepted standards of care. I have been given the opportunity to ask questions regarding the nature and purpose of proposed services and possible alternatives.

I acknowledge that no guarantee has been made as to the results of these services and that complications, though uncommon, may occur. I understand I may refuse any part of the proposed care and that I may withdraw consent at any time, except to the extent that action has already been taken in reliance on this consent.

Financial Responsibility: I authorize release of information necessary to process claims and assign benefits to Healthcare Wellness Clinics. I accept responsibility for charges not covered by insurance, co-payments, deductibles, and non-covered services. I agree that reimbursement may be sought from me for services denied by my insurer.

I consent to treatment and billing authorization as described above.

Authorization to Disclose Protected Health Information

By signing below I authorize Healthcare Wellness Clinics to use and disclose my protected health information for treatment, payment, and healthcare operations. I also authorize the release of my medical information to the persons listed below and understand that such disclosures may include medical records, test results, and visit notes.

This authorization will remain in effect until:

I understand I may revoke this authorization in writing at any time, except to the extent action has already been taken in reliance on it. Revocation must be submitted to the clinic in writing and will not affect disclosures made prior to receipt of the revocation.

Privacy and Communication Preferences

Acknowledgment of Notice of Privacy Practices: I acknowledge that I have been offered a copy of the clinic's Notice of Privacy Practices that describes how my health information may be used and disclosed. I understand my rights regarding my health information.

I acknowledge receipt or offer of the Notice of Privacy Practices.

May we leave messages regarding appointments or medical information on your voicemail or with a household member? Yes No

Telehealth (if applicable)

I consent to the use of telehealth modalities (video or telephone) when offered by the clinic. I understand there are risks, benefits, and alternatives to telehealth, including limitations in establishing a clinician-patient relationship and potential privacy risks.

I consent to telehealth services as described above.

Certification

I certify that the information on this form is true and accurate to the best of my knowledge. I understand that providing false information may affect treatment and insurance claims. I have read and understand the statements above and accept the terms of consent, authorization, and financial responsibility.

I certify the information provided is true and I accept the terms above.

Sign Now