Healthcare WHNP Form

Healthcare WHNP Form

This form collects medical, reproductive, and administrative information for evaluation and treatment by a Women's Health Nurse Practitioner (WHNP). Information provided will be used for diagnosis, treatment, billing, and care coordination. Complete all applicable fields and sign the certification at the end to authorize care and release of information as described below.

Patient Information

Patient Name:    Date of Birth:

Female    Male    Non-binary/Other

Emergency Contact

Insurance Information

Medical & Gynecologic History

Current tobacco use: Yes    No     Alcohol use: Yes    No

Reproductive & OB-GYN Details

Last Menstrual Period (LMP):    Age at Menarche:

Gravida (total pregnancies):    Para (live births):    Abortions/Miscarriages:

Currently pregnant: Yes    No     If pregnant, estimated due date:

None    Oral contraceptive    IUD    Implant    Other:

Presenting Concerns / Reason for Visit

Clinical Consent & Authorization

I consent to evaluation, examination, diagnostic testing, and treatment provided by the WHNP and clinical staff. I understand that the WHNP practices within the scope of nurse practitioner licensure and will consult or refer to other licensed practitioners as clinically indicated. The WHNP has explained the nature, expected benefits, and material risks of recommended examinations and treatments. I acknowledge the right to ask questions and to decline any procedure or treatment prior to its initiation.

I authorize the release of necessary medical information to insurance carriers, other health care providers, and entities involved in my care for purposes of treatment, payment, and health care operations. This authorization includes diagnostic test results and treatment summaries but excludes psychotherapy notes unless specifically authorized below.

I understand that I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance on it. Unless revoked earlier, this authorization will expire on: .

HIPAA Privacy Acknowledgment

I acknowledge that I have been offered a copy of the privacy practices notice describing how my protected health information may be used and disclosed, and how I may obtain access to this information. I understand that my health information may be used for treatment, payment, and health care operations and that I may request restrictions or confidential communications in writing.

Certification

I certify that the above information is true and accurate to the best of my knowledge. I consent to care provided by the WHNP and clinical staff. I understand the financial responsibility for services rendered and agree that information necessary for billing and coordination of care may be disclosed to my insurer and other health care providers as needed.

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