Healthcare Wellness Design

HEALTHCARE WELLNESS DESIGN

Patient Information

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Subscriber Date of Birth:

Medical History

Wellness Assessment & Goals

Presenting concerns and objectives:

Proposed Wellness Design / Plan

Risks, Benefits & Alternatives

I acknowledge that the proposed wellness plan may include exercise, dietary modification, behavioral coaching, biometric monitoring, or therapeutic modalities. Benefits may include improved physical or mental health outcomes, while risks may include musculoskeletal strain, allergic reactions, or transient symptom exacerbation. Reasonable alternatives including no treatment, modified interventions, or referral to specialty care have been explained.

By checking the box, I acknowledge I have had the opportunity to ask questions, and my questions have been answered to my satisfaction.

Consent & Authorization

I authorize the providers and staff of this practice to provide the wellness services and interventions described above. I consent to collection of health information necessary for assessment, treatment planning, and program evaluation. I understand that I may withdraw this consent at any time by providing written notice, except to the extent that action has already been taken in reliance on this authorization.

This authorization includes release of relevant health information to other treating providers, laboratories, or billing agents as necessary for treatment, payment, or health care operations. I authorize release of information for insurance claims or program coordination as indicated below.

Authorization expires on:

Share information necessary for care coordination and billing: Share with other treating providers Share with insurer / payer

Financial responsibility: I accept responsibility for charges not covered by insurance, including co-payments, deductibles, and services designated as patient-responsibility. If claiming third-party payment, I authorize release of information necessary to process claims.

HIPAA / Privacy Acknowledgment

I acknowledge receipt of the practice's Notice of Privacy Practices describing how my health information may be used and disclosed. I understand my rights regarding protected health information, including the right to request restrictions, inspect and obtain copies of my record, and request an amendment. I understand limitations to confidentiality may apply in cases required by law.

I acknowledge that I have been offered an opportunity to discuss privacy practices and ask questions.

Patient Responsibilities & Acknowledgment

I agree to attend scheduled sessions, adhere to agreed treatment elements, and promptly inform the provider of any significant changes in my health status. I understand that outcomes cannot be guaranteed and that success depends on active participation and adherence to the plan.

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