Mental Health Questionnaire – SpecialtyHealth Wellness and Prevention Programs

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Patient Information and Consent
Title*
Name*
First Middle Initial Last
Date of Birth*
Gender*
- Male
- Female
Ethnicity*
Health risk may vary depending on ethnicity
Marital Status
Address*
Street Address City State ZIP Code
Home Phone*
Cell Phone*
Email Address*
Employer*
If employer is not listing, please select Private Individual
Occupation
Years in Occupation
Work Phone*
Spouse Name
Spouse/Parents' Employer
Spouse's Work Phone

Authorization
Authorization*
AUTHORIZATION: I hereby consent to and authorize the treating physician, associated personnel, and any other consulting physician called in by the above, to assess or provide first aid and to render medical treatment and health care services to the patient named on this form. I further consent to and authorize procedures or services which may be deemed necessary by said designated or consulting physician. I have been given no guarantee and rely on none as to the result of any assessment, first aid, treatment, or examinations. I am aware that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantees have been made to me as to the results of any assessment, first aid, diagnostic, medical, surgical, or therapeutic treatments, procedures, or examinations.

DISCLAIMER: This is not an insurance product. Many of the items may not be covered by your insurance company and therefore will be your responsibility. Healthcare professional availability for certain services may be dependent on licensure, scope of practice restrictions, or other requirements in the state. The information provided is not a substitute for your doctor’s care and should be used as a practical guide to better health through lifestyle choices.

I hereby authorize the physicians and staff involved in SpecialtyHealth's Wellness and Prevention Program to utilize my medical information obtained through the Wellness and Prevention Program for the purpose of research. Research may include individual case studies and/or compilations of group/population data, which may be published and/or presented in lectures. All personal and medical information will be kept confidential. A personal ID will be assigned to each individual participant to protect his/her privacy.

ASSIGNMENT OF BENEFITS: I authorize the release of any medical information necessary to process this claim. I also request payment of health insurance benefits to the physician's office, who accepts assignment. I hereby authorize payment directly to SpecialtyHealth of any monetary benefits from my medical plan. I understand that I am responsible for my account, regardless of insurance involvement. I understand that my insurance plan may not cover Nutrition or other Wellness Services, and I will be responsible for any portion not covered by my insurance. I hereby authorize SpecialtyHealth to release my medical records to my insurance carriers. I further authorize payments of medical benefits to be paid directly to the physicians for services rendered. This agreement will be in effect until otherwise modified. NOTICE: you are entitled to a copy of yours records upon request; however, pursuant to Nevada law, your records may be destroyed after 6 years.

ACKNOWLEDGEMENT OF RECEIPT: I have received, or I have been provided the opportunity to receive a copy of the "Notice of Privacy Practices" that explains when, where, and why my confidential health information may be used or shared. I acknowledge that SpecialtyHealth Clinic, the physicians, the nurses, and other SpecialtyHealth staff may use and share my confidential health information with others in order to treat me, in order to arrange for payment of my bill, and for issues that concern SpecialtyHealth's operations and responsibilities. I further acknowledge that I understand that if I have any questions regarding this Notice or wish to file a complaint, I may contact the SpecialtyHealth Privacy Officer in writing. I also understand that no other staff member, physician, nurse, or any other person is authorized to accept a request to exercise my rights but the Privacy Officer for SpecialtyHealth Clinic.

Notice of Privacy Practices
Federal law requires that we seek your acknowledgement of receipt of this Notice of Privacy Practices, effective April 14, 2003. Please signify your acknowledgement with your signature beneath the following statement (Release of Information to Someone Designated by The Patient):

Release of Information to Someone Designated by the Patient

According to the HIPAA compliance for Protected Health Information (PHI), it is necessary to provide SpecialtyHealth Clinic with name(s) of the following individual(s) with whom they may share my protected health information (PHI). It is with my informed consent that these individuals are able to speak with, be given written prescriptions and orders for procecure(s) and discuss health care; options if I am unable to do so. It is also my understanding that I may revoke this consent at any time; as long as the revocation is in writing with a signature, effective date and is received at the office of SpecialtyHealth.

SpecialtyHealth will not disclose my medical information to any person or entity unless I specifically authorize such disclosure in writing or SpecialtyHealth is required by law to make such disclosure.

I agree to the authorization
Designated Individual(s) Authorized to receive my Personal Health Information (PHI):
Please include name and relationship to the patient
Comments
This field is for validation purposes and should be left unchanged.

Patient Information and Consent

Authorization