Healthcare Wellness SOF

Healthcare Wellness SOF

Purpose: This Statement of Wellness (SOF) documents the patient’s current health status, screening findings, documented recommendations, and the patient’s informed consent for participation in wellness services offered by the provider identified below. Information provided herein will be used for clinical assessment, care planning, and coordination with ancillary services as authorized below.

Patient Information

Patient Name:

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History & Current Status

Lifestyle & Preventive Screening

Tobacco use:    Alcohol use:

Wellness Assessment Findings & Plan

Consent for Wellness Assessment and Participation

I acknowledge that the wellness assessment and any recommended screenings are intended to identify health risks and support preventive health. I understand that tests, measurements, or non-invasive procedures may be recommended. I have had the opportunity to ask questions about the nature and purpose of the services and understand the risks, benefits, and alternatives. I understand that no specific outcome is guaranteed.

I voluntarily consent to participate in the wellness services described above and any routine non-invasive screenings performed as part of my care. I understand I may withdraw this consent at any time by providing written notice to the provider, except to the extent that action has already been taken in reliance on this consent.

I consent to participate in the wellness assessment and associated non-invasive screenings.

I consent to referral and communication with other health professionals for care coordination as indicated.

HIPAA Privacy Acknowledgment & Authorization

I acknowledge receipt of the provider’s privacy practices and understand that my protected health information may be used and disclosed for treatment, payment, and health care operations as described in that notice. I authorize the release of protected health information to individuals and entities involved in my care, only to the minimum extent necessary.

I acknowledge receipt of the privacy practices and consent to the uses and disclosures described therein.

Authorization to Release Records

I authorize the release of my wellness assessment record and related clinical information to the following person(s) or organizations for the purposes stated.

Authorization Expiration:    Limit release to specific items only

I understand that this authorization is voluntary. I may revoke it in writing at any time, except to the extent that action has already been taken in reliance upon it. Unless revoked earlier, this authorization will expire on the date provided above or, if no date is provided, one year from the date of signature.

Certifications and Acknowledgements

By signing below I certify under penalty of perjury that the information I have provided on this Statement of Wellness is true and accurate to the best of my knowledge. I acknowledge that I have had the opportunity to ask questions about the proposed wellness services and that those questions have been answered.

I understand that participation in wellness services is voluntary and that I may withdraw from the wellness program at any time by notifying the provider in writing. I authorize the use and disclosure of my protected health information as described in this document to facilitate care, referrals, and coordination related to the wellness plan.

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