Healthcare Wellness Consent Form

HEALTHCARE WELLNESS CONSENT FORM

Patient Information

Patient Name:    Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History

Wellness Service / Procedure

Description of wellness services to be provided (examples include biometric screening, immunizations, health coaching, point-of-care testing, counseling, nutritional assessment). Services requested and explained to me:

I understand the purpose, anticipated benefits, common risks, and limits of the described wellness services. Common risks and side effects may include, but are not limited to: minor bruising, temporary discomfort at the site of testing or injection, fainting, allergic reaction, inaccurate or inconclusive screening results, and emotional distress from health information disclosed during assessment. Serious complications are uncommon.

Risks, Benefits, and Alternatives

Benefits include early identification of health risks, counseling, preventive treatment, and referral to appropriate care. Reasonable alternatives to the proposed services include declining all or part of the services, obtaining similar services from another provider, or pursuing diagnostic services through the primary care provider. I have had the opportunity to ask questions and have received satisfactory answers.

By checking the box below I acknowledge that the provider has explained the nature and purpose of the wellness services and associated risks in language that I understand.

I acknowledge that risks, benefits, and alternatives were explained and I understand them.

Consent to Treatment and Authorization

I voluntarily consent to the performance of the wellness services described above and to any routine ancillary procedures necessary for my care. I authorize trained personnel to perform the services and to administer medications, vaccines, or tests as appropriate for those services. I understand that no guarantee has been made to me concerning the results of any procedure.

I understand that I may withdraw this consent at any time prior to or during the service by informing the provider. Withdrawal of consent will not affect the provider's right to use information obtained prior to withdrawal to the extent permitted by law.

I consent to receive the wellness services described above.

Privacy, Records, and Release of Information (HIPAA)

My protected health information created or obtained in the course of providing these services may be documented in the provider's medical record and used for treatment, billing, and healthcare operations. I authorize the release of relevant health information to my insurer, primary care provider, and other third parties as necessary to facilitate continuity of care and payment. I acknowledge receipt of the provider's privacy notice and understand my rights regarding access to and amendment of my health information.

I acknowledge that I have been provided with the privacy practices notice and authorize release of protected health information as described above.

Authorization Duration and Revocation

This authorization to use and disclose my health information and to provide the requested wellness services will remain in effect until: unless revoked earlier in writing. I understand that revocation will not affect disclosures already made under this authorization.

Financial Responsibility

I understand that some wellness services may be billed to my insurance and that I may be responsible for co-payments, deductibles, or charges not covered by insurance. I authorize the provider to submit claims to my insurer and to obtain payment directly to the provider for services rendered.

Additional Acknowledgments

I certify that the information I have provided on this form is true and complete to the best of my knowledge. I understand that intentionally providing false information may affect the quality of care and my eligibility for certain services.

Consent and Signature

By signing below I attest that I am the patient named above or the legally authorized representative of the patient. I have read and understand this consent and authorization and accept the terms stated herein.

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