Healthcare Worksheet

HEALTHCARE WORKSHEET

This Healthcare Worksheet collects current medical, insurance, and contact information required to provide safe and effective care. Provide complete and accurate responses. By signing this form you certify the information is true to the best of your knowledge and you give the clinic authority to use this information for treatment, payment, and healthcare operations as described in the acknowledgments below.

Patient Information

Patient Name:

Date of Birth:    Gender:    Preferred Pronouns:

Primary Phone:    Alternate Phone:

Emergency Contact

Contact Name:    Relationship:

Contact Phone:

Insurance Information

Policy Number:    Group Number:

Subscriber Date of Birth:

Medical History

Diabetes    Hypertension    Heart disease    Asthma / COPD

Cancer    Kidney disease    Thyroid disorder    Mental health condition

None of the above    Other:

Social / Preventive Health

Current smoker:    Alcohol use:    Recreational drug use:   

Influenza    COVID-19    Tdap    Other:

Presenting Problem / Symptoms

Clinical Measurements

Height:    Weight:    Blood Pressure:

Acknowledgments & Authorizations

I authorize clinicians and staff to provide evaluation and medically necessary treatment. I authorize the release of medical information to insurers, other health providers, and billing agents as necessary for claims processing, quality review, and care coordination. I assign benefits to the provider for payment of covered services and acknowledge responsibility for charges not paid by insurance. This authorization includes communication by telephone or electronic message; I consent to being contacted at the telephone numbers and email provided above unless I notify the office otherwise.

I understand that I may revoke this authorization in writing at any time, except where action has already been taken in reliance on this authorization. This authorization will remain in effect until the expiration date specified below or until revoked in writing, whichever occurs first.

I consent to evaluation and treatment.    I assign benefits and authorize billing to my insurer.    I authorize release of health information as necessary for care and billing.

I acknowledge receipt of the Notice of Privacy Practices and understand my rights regarding protected health information.

Authorization expiration date:

I certify under penalty of perjury that the information provided on this Healthcare Worksheet is true and complete to the best of my knowledge. I understand that providing false information may affect my care and insurance coverage and may subject me to financial liability.

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