Veteran Assessment Consent Form
SERENE BOLD HEALTH CLINIC
4606 FM 1960 W, Ste 224, Houston TX, 77069
Email: Contactus@sereneboldhealthclinic.com
Phone: 281-944-5692 
Fax: 281-944-5693

GENERAL CONSENT FOR SERVICES

You have the right, as a patient, to be informed about your condition and the recommended medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended.

This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s) I voluntarily request a mid level provider (Nurse Practitioner)and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice.


This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that 

(1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and
(2) The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services.

Consent is hereby given to Serene Bold Health Clinic provider and its employees to provide medical services and clinician's orders, retrieve and review my medical record/electronic medical record which includes my medication list and other medical information necessary to facilitate electronic prescribing. You have the right to discuss the treatment plan with your provider about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions.

I certify that all the information given by me which includes my name, address, telephone number, and insurance information are correct to the best of my knowledge and that I am authorized to inform
Serene Bold Health Clinic of any changes immediately.

I hereby authorize Serene Bold Health Clinic to furnish information to insurance carriers, referring physicians/mid level providers, and other healthcare agencies concerning illness and treatment with respect to services rendered.

NOTICE OF PRIVACY PRACTICES

Federal law sets rules for health care providers and health insurance companies about who can look at and receive our health information. This law, called the Health Insurance Portability and Accountability Act of 1996 (HIPAA), gives you rights over your health information, including the right to get a copy of your information, make sure it is correct, and know who has seen it. You can ask to see or get a copy of your medical record and other health information.
If you want a copy, you may have to put your request in writing and pay for the cost of copying and mailing. You can ask to change any wrong information in your file or add information to your file if you think something is missing or incomplete. By law, your health information can be used and shared for specific reasons not directly related to your care, like making sure doctors give good care, reporting when the flu is in your area, or reporting as required by state or federal law. In many of these cases, you can find out who has seen your health information.
You can: Learn how your health information is used and shared by your doctor or health insurer. Generally, your health information cannot be used for purposes not directly related to your care without your permission.
For example, your doctor cannot give it to your employer without your written authorization.
Let your providers or health insurance companies know if there is information you do not want to share.
You can ask for other kinds of restrictions, but they do not always have to agree to do what you ask, particularly if it could affect your care.
Finally, you can also ask your health care provider not to tell your health insurance company about care you receive or drugs you take, if you pay for the care or drugs in full and the provider does not need to get paid by your insurance company.
Acknowledgement of Receipt of Notice of Privacy Practices The Notice of Privacy Practices is a complete description of my rights as a patient of SBHC. 

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Email *
Acknowledgment *
My full name entered before indicates that I have read and received the SBHC notice of general consent for services and notice of privacy practices. (Enter first and last name below)
Referral source: How did you hear about us? *
Patient first and last name *
Patient date of birth *
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Social security number
Patient legal gender *
Marital status *
Patient contact number *
Phone type *
Email address *
Home street address  *
City *
Home zip code
*
Emergency contact full name
*
Emergency contact phone number
*
Emergency contact relation to patient
*
friend/spouse/son
Patient Legal Guardian Name (if applicable)
Legal guardian first and last name
Patient legal guardian phone number
Patient legal guardian email
Today's date
*
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YYYY
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