Patient Intake Form - Breathewell Pulmonary Clinic

1. Consent for Medical Treatment

I, the undersigned, voluntarily consent to the medical treatment and diagnostic procedures that are deemed necessary by the healthcare providers at BreatheWell Pulmonary Clinic. I understand that treatment may include physical exams, laboratory tests, imaging, and other diagnostic or therapeutic procedures as necessary for my care.

2. Financial Responsibility & Insurance

I understand that I am responsible for all charges incurred during my treatment. If my insurance does not cover services, I agree to pay any remaining balance. I authorize BreatheWell Pulmonary Clinic to release any medical information necessary for billing purposes to my insurance provider.

3. Release of Medical Information

I authorize the release of my medical information to my referring physician, primary care provider, or other specialists involved in my care. I also understand that my medical records will be kept confidential and will not be disclosed without my written consent, except as required by law.

Authorization for Family Member Access (Optional)

I authorize Breathewell Pulmonary Clinic to release my medical information to the following individual:

This authorization allows the named individual to discuss my treatment, appointments, and billing information with Breathewell Pulmonary Clinic. I understand that I may revoke this authorization at any time in writing.

4. Telehealth Consent (if applicable)

I understand that telehealth services may be offered as part of my care. I consent to receive healthcare services via telecommunication and understand the risks, benefits, and limitations of telehealth.

5. Acknowledgment & Signature

By signing below, I acknowledge that I have read, understood, and agree to the terms outlined in this consent form.