new patient intake form template word

Medical Practice Patient Registration and Intake Agreement

Instructions for Use

• Complete all sections in full; ensure that legal names match government-issued identification.
• Review the privacy and consent clauses carefully before signing to ensure alignment with your practice's specific data handling policies.
• Save a digital copy in the patient’s electronic health record (EHR) and provide a signed physical or digital copy to the patient for their personal files.

Parties and Definitions

This Intake Agreement is entered into by and between [Practice Name] (hereinafter "Provider") and [Patient Full Legal Name] (hereinafter "Patient"). If the Patient is a minor or under legal guardianship, the representative signing below shall be referred to as the "Authorized Representative."

Operative Terms and Conditions

1. Patient Information:

   • Full Legal Name: [__________]
   • Date of Birth: [__________]
   • Primary Phone: [__________]
   • Email Address: [__________]
   • Emergency Contact Name/Phone: [__________]

2. Insurance and Financial Responsibility:

   • Insurance Provider: [__________]
   • Member ID: [__________]
   • I acknowledge that I am responsible for all charges incurred, regardless of insurance coverage. I authorize the release of medical information necessary to process insurance claims.

3. Consent to Treatment:

   • I voluntarily consent to the medical care, diagnostic tests, and treatment procedures ordered by the Provider. I understand that I have the right to discuss the nature of these procedures with my physician.

4. Privacy and HIPAA Acknowledgment:

   • I acknowledge that I have received or have been offered the Notice of Privacy Practices, which explains how my protected health information (PHI) may be used and disclosed.

5. Communication Policy:

   • I authorize the Provider to contact me via:
     • Phone
     • Email
     • Secure Patient Portal
   • I understand that standard email may not be encrypted and I accept the risks associated with electronic communication.

6. Cancellation and No-Show Policy:

   • Appointments must be canceled at least [] hours in advance. Failure to provide sufficient notice may result in a fee of $[].

7. Governing Law:

   • This agreement shall be governed by the laws of the State of [__________].

Signature and Acknowledgment

By signing below, I certify that the information provided is true and accurate to the best of my knowledge, and I agree to the terms outlined above.

Signature: __________

Printed Name: [__________]

Title (if signing for Patient): [__________]

Date: [__________]

Legal Disclaimer

This document is a general framework intended for informational purposes only. It does not constitute legal advice. Because medical privacy laws, billing regulations, and consent requirements vary significantly by jurisdiction, you must consult with qualified legal counsel to ensure this document complies with all applicable state and federal laws.