Healthcare Wellness Document

HEALTHCARE WELLNESS DOCUMENT

Clinic/Practice Name:    Provider Name:

Date of Visit:

Patient Information

Date of Birth:    Gender: Male Female Other Prefer not to say

Emergency Contact

Insurance Information

Medical History & Current Status

Lifestyle & Preventive Screening

Do you currently smoke or use tobacco products? Yes No

Do you consume alcohol? Yes No

Wellness Services / Consent

I acknowledge that the wellness services described above have been explained to me, including their nature, anticipated benefits, reasonably foreseeable risks, and available alternative options. I understand I may refuse any service or withdraw consent at any time by informing the provider in writing, except to the extent that action has already been taken in reliance on this consent.

Consent to receive wellness services: I consent to the wellness services described above and to any routine assessments associated with those services.

Authorization to Use and Disclose Health Information (HIPAA)

I authorize the release and exchange of my protected health information (PHI) necessary for treatment, payment, and health care operations related to the services provided under this document, including but not limited to communication with my insurer and coordination with my primary care provider. This authorization includes release of relevant medical records, test results, and treatment notes to the extent necessary to carry out these purposes.

I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by privacy laws. I may revoke this authorization in writing at any time, except to the extent the provider has acted in reliance on it.

Permission to disclose to emergency contact / family: I authorize disclosure of treatment information to the emergency contact listed above.

Acknowledgments & Certifications

By signing below I certify that the information I have provided on this form is true and complete to the best of my knowledge. I authorize the clinic and its agents to bill my insurance and to obtain payment directly for services rendered. I understand I am financially responsible for services not covered or denied by my insurer. I acknowledge receipt of the provider's privacy practices and understand my rights regarding my health information.

I understand that I may request a copy of this signed document. This authorization and consent remain in effect until the authorization expiration date specified above or until I revoke it in writing, whichever occurs first.

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