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Consent Form

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Consent Form

Patient ID *

Patient Name *

Patient Email

Patient Phone Number

Sex *

Male

Female

Marital Status *

Single

Married

Widowed

Divorced

Date of birth *

Address *

Driver's License / ID

Emergency Contact

Emergency Contact Name
*

Emergency Contact Phone
*

Emergency Contact Email

Relationship *

Primary Doctor *

Authorization and Release

I authorize my insurance company to pay Grand View General Hospital all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges not paid by insurance. Grand View General Hospital may use my health care information and may disclose such information to my insurance company(ies) and their agents for the purpose of obtaining payment for the services and determining insurance benefits payable for related services, as pertaining to the HIPAA guidelines.

Patient Signature *

Clear

Date signed

Consent Form

Click Submit to finish.