Curana Health New Patient Consent

CURANA HEALTH Consent to Treat
Primary CareSecondary Care
Patient Name*
Date of Birth*

MonthDayYear
Date
Patient State*
Patient or Patient Representative Phone Number*
Patient or Patient Representative Email Address*
example@example.com
Senior Living Residence Name*
Residential Setting (please check a box that best describes your senior living residence):*

Indepdendent LivingAssisted LivingMemory CareLong-Term Care/Skilled Nursing
COMMUNICATION PREFERENCES
I prefer to be contacted by:

EmailPhoneBoth email and phoneI consent to receiving marketing messages from Curana Health.
BY CHECKING THE BOXES BELOW, YOU ARE CONSENTING TO THE DESCRIBED SERVICE(S):
General Consent to Treat: TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical, behavioral health, or diagnostic procedure to be used SO that you may make the decision to undergo any suggested treatment or procedure after knowing the potential benefits as well as the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form provides us with your permission to perform any reasonable and necessary evaluation to identify the appropriate treatment and/or procedure for any identified condition(s), as well as any reasonable and necessary medical examinations, testing, and treatment for the same.
General Consent to Treat: TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical, behavioral health, or diagnostic procedure to be used SO that you may make the decision to undergo any suggested treatment or procedure after knowing the potential benefits as well as the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form provides us with your permission to perform any reasonable and necessary evaluation to identify the appropriate treatment and/or procedure for any identified condition(s), as well as any reasonable and necessary medical examinations, testing, and treatment for the same.
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; (2) you consent to treatment by any Curana Health and its affiliated entities' provider, (3) you consent to communication via electronic and/or written format, and (4) you consent to the release of information to your healthcare providers as necessary for continued patient care and other related purposes. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services. You have the right to discuss the treatment plan with your provider, including the purpose, potential risks, and benefits of any test or treatment ordered for you. If you have any concerns regarding any test or treatment recommended by your health care provider, we encourage you to ask questions of your Curana provider.

I voluntarily request a physician, and/or mid-level provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other health care providers or their designees as deemed necessary (collectively "Curana Provider"), to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice.

I understand that my Curana provider may be required by law to repost suspected abuse or neglect or to disclose my private information if they believe I may harm myself or others.
Consent to Use of Telehealth: Circumstances may arise where medically necessary telehealth visits are required to address your medical needs, including but not limited to after hours and on weekends. By signing below, (1) I intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; (2) I consent to treatment by any Curana Health and its affiliated entities' provider; (3) I consent to communication via electronic and/or written format; and (4) to the extent I initiate any such virtual or telephonic visit, I consent to medical examination and treatment via telephonic, video, or other virtual modalities. This consent will remain fully effective until it is revoked in writing. I have the right at any time to discontinue services. I have the right to discuss the treatment plan with my provider, including the purpose, potential risks and potential benefits of any test or treatment ordered for me. If I have any concerns regarding any test or treatment recommended by my health care provider, Curana encourages me to ask questions of my Curana provider.
Consent to Use of Telehealth: Circumstances may arise where medically necessary telehealth visits are required to address your medical needs, including but not limited to after hours and on weekends. By signing below, (1) I intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; (2) I consent to treatment by any Curana Health and its affiliated entities' provider; (3) I consent to communication via electronic and/or written format; and (4) to the extent I initiate any such virtual or telephonic visit, I consent to medical examination and treatment via telephonic, video, or other virtual modalities. This consent will remain fully effective until it is revoked in writing. I have the right at any time to discontinue services. I have the right to discuss the treatment plan with my provider, including the purpose, potential risks and potential benefits of any test or treatment ordered for me. If I have any concerns regarding any test or treatment recommended by my health care provider, Curana encourages me to ask questions of my Curana provider.
Consent to Use of Remote Medical Monitoring Devices: I voluntarily request my Curana Provider to use remote medical monitoring devices as reasonable and medically necessary to identify, evaluate, and monitor any medical conditions or diagnoses I may have and determine appropriate treatment and/or procedures for those conditions or diagnoses. Remote medical monitoring devices may include, as determined by my Curana Provider, devices to monitor blood pressure, heart rate, weight, falls, sleep disturbances, and blood sugar, among other clinically important measures. I acknowledge and consent that some of these devices may involve devices that are installed in my room at my medical facility that will continually monitor my relevant health measures. I acknowledge that any remote medical monitoring devices are not intended to be emergency response devices and that while data is collected continually, the data stream is only reviewed at set intervals for limited purposes. I expressly acknowledge and agree that I will not rely on the existence of these devices in the event of a medical emergency but will contact 911 or the medical staff on duty in my facility.
Consent to Use of Remote Medical Monitoring Devices: I voluntarily request my Curana Provider to use remote medical monitoring devices as reasonable and medically necessary to identify, evaluate, and monitor any medical conditions or diagnoses I may have and determine appropriate treatment and/or procedures for those conditions or diagnoses. Remote medical monitoring devices may include, as determined by my Curana Provider, devices to monitor blood pressure, heart rate, weight, falls, sleep disturbances, and blood sugar, among other clinically important measures. I acknowledge and consent that some of these devices may involve devices that are installed in my room at my medical facility that will continually monitor my relevant health measures. I acknowledge that any remote medical monitoring devices are not intended to be emergency response devices and that while data is collected continually, the data stream is only reviewed at set intervals for limited purposes. I expressly acknowledge and agree that I will not rely on the existence of these devices in the event of a medical emergency but will contact 911 or the medical staff on duty in my facility.
Consent to Use of Ambient Recording of Medical Visit for Charting Purposes: I understand that my Curana Provider has access to a tool to assist them in completing their medical charts. This tool will record the conversation between me and my Curana Provider during my medical visit SO that my Curana Provider will be able to have a record of our conversation for charting purposes after the visit. The conversations are stored securely where no one else can access them and are deleted after the provider has completed the medical chart documentation. The provider will turn the tool on to record at the beginning of the medical visit with me and turn it off at the end of the visit with me. The tool will not record any other conversations outside of the medical visit nor will it remain in my room when the provider is not in my room. The tool will assist my Curana Provider in completing the medical chart by providing the content of our conversation during the visit in a written format that the Curana Provider can then use to complete the chart. I consent to my Curana Provider's use of this tool for the purpose of ensuring that my medical records are complete and accurate.
Consent to Use of Ambient Recording of Medical Visit for Charting Purposes: I understand that my Curana Provider has access to a tool to assist them in completing their medical charts. This tool will record the conversation between me and my Curana Provider during my medical visit SO that my Curana Provider will be able to have a record of our conversation for charting purposes after the visit. The conversations are stored securely where no one else can access them and are deleted after the provider has completed the medical chart documentation. The provider will turn the tool on to record at the beginning of the medical visit with me and turn it off at the end of the visit with me. The tool will not record any other conversations outside of the medical visit nor will it remain in my room when the provider is not in my room. The tool will assist my Curana Provider in completing the medical chart by providing the content of our conversation during the visit in a written format that the Curana Provider can then use to complete the chart. I consent to my Curana Provider's use of this tool for the purpose of ensuring that my medical records are complete and accurate.
Consent to Request Medical Records from Other Providers: I understand that in order for my Curana Provider to provide the best care to me, my Curana Provider needs a complete picture of my medical history and medical care. I hereby authorize Curana and my Curana Provider to obtain my medical records from all other health care providers, past or present, from whom I have received or am receiving care or treatment, in any form, including, without limitation, from any Health Information Exchange or Electronic Health Record in which those records might be stored. This authorization is continuing for as long as I am a patient of Curana and my Curana Provider unless I revoke this authorization in writing addressed to the Curana Chief Compliance Officer at 8911 North Capital of Texas Hwy Building 1, Suite 1110, Austin, TX 78759.
Consent to Request Medical Records from Other Providers: I understand that in order for my Curana Provider to provide the best care to me, my Curana Provider needs a complete picture of my medical history and medical care. I hereby authorize Curana and my Curana Provider to obtain my medical records from all other health care providers, past or present, from whom I have received or am receiving care or treatment, in any form, including, without limitation, from any Health Information Exchange or Electronic Health Record in which those records might be stored. This authorization is continuing for as long as I am a patient of Curana and my Curana Provider unless I revoke this authorization in writing addressed to the Curana Chief Compliance Officer at 8911 North Capital of Texas Hwy Building 1, Suite 1110, Austin, TX 78759.
Assignment of Professional Benefits: I hereby assign all insurance benefits and/or Medicare/ Medicaid benefits to Providers and/or medical professionals providing services to me and authorize direct payment to Providers. This assignment specifically includes, but is not limited to, major medical and disability insurance proceeds and benefits. I agree to pay for any and all charges not paid pursuant to this assignment. A photocopy of this assignment shall be valid as the original.
Assignment of Professional Benefits: I hereby assign all insurance benefits and/or Medicare/ Medicaid benefits to Providers and/or medical professionals providing services to me and authorize direct payment to Providers. This assignment specifically includes, but is not limited to, major medical and disability insurance proceeds and benefits. I agree to pay for any and all charges not paid pursuant to this assignment. A photocopy of this assignment shall be valid as the original.
Statement of Responsibility: I understand that I am financially responsible to my Curana Provider as the patient, insured, or in my fiduciary capacity as a representative for the patient or insured for all charges not covered by the above assignment. Charges may include co- payments, insurance deductibles, co-insurance or out-of-pocket expenses.
Statement of Responsibility: I understand that I am financially responsible to my Curana Provider as the patient, insured, or in my fiduciary capacity as a representative for the patient or insured for all charges not covered by the above assignment. Charges may include co- payments, insurance deductibles, co-insurance or out-of-pocket expenses.
Health Plan Statement: Unless I am a member of the following health plans, I understand that my Curana Provider is not providing treatment on behalf of health maintenance organization membership: Align Senior Care, AgeRight Advantage, Pruitt Health Premier, ProCare, NHC Advantage, KeyCare, Perennial, and Lifeworks Advantage.
Health Plan Statement: Unless I am a member of the following health plans, I understand that my Curana Provider is not providing treatment on behalf of health maintenance organization membership: Align Senior Care, AgeRight Advantage, Pruitt Health Premier, ProCare, NHC Advantage, KeyCare, Perennial, and Lifeworks Advantage.
Notice of Privacy Practice: I understand that the Medical Group Notice of Privacy Practices describes how medical information about me may be used and disclosed. I acknowledge that the Medical Group Notice of Privacy Practices is available for me to access online, at CuranaHealth.com/Privacy-Policy/ and is also available upon request.
Notice of Privacy Practice: I understand that the Medical Group Notice of Privacy Practices describes how medical information about me may be used and disclosed. I acknowledge that the Medical Group Notice of Privacy Practices is available for me to access online, at CuranaHealth.com/Privacy-Policy/ and is also available upon request.
To read the Notice of Privacy Practice, scan the QR code on the left.
I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents. I also acknowledge that I have been given a copy of Curana's Notice of Privacy Practices.
I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents. I also acknowledge that I have been given a copy of Curana's Notice of Privacy Practices.
Signature of Patient or Patient Representative*

Clear
Date*

MonthDayYear
Date
Printed Name of Patient or Patient Representative*
Relationship to Patient*
*If signed by a Patient Representative, please include signing authority paperwork along with this consent form.
Protected Health Information
Patient Name*
Date of Birth*

MonthDayYear
Date
In general, the HIPAA Privacy Rule gives an individual the right to request a restriction on the uses and disclosures of Protected Health Information (PHI Please indicate your preferences regarding

I wish to be contacted in the following manner (check all that apply):
ORAL COMMUNICATION
Home Phone:
Please enter a valid phone number.
Okay to leave detailed messageLeave message with call-back number only
Cell Phone:
Please enter a valid phone number.
Okay to leave detailed messageLeave message with call-back number only
Other:
Please enter a valid phone number.
Okay to leave detailed messageLeave message with call-back number only
WRITTEN COMMUNICATION
Okay to mail information including PHI to my home address
OTHER COMMUNICATION
I permit the practice to discuss and disclose my PHI with/to:
Spouse:
First & Last Name
Phone
Children:
First & Last Name
Phone
First & Last Name
Phone
First & Last Name
Phone
First & Last Name
Phone
First & Last Name
Phone
First & Last Name
Phone
First & Last Name
Phone
Other:
First & Last Name
Phone
Signature

Clear
Date

MonthDayYear
Date
Authorization To Release Healthcare Information To Curana Health
Patient Name*
Date of Birth*

MonthDayYear
Date
Patient Address*
Social Security Number*
Your previous healthcare providers name
to release healthcare information of the patient named above to Curana Health at:
Curana Health facility/community name
Curana Health mailing address/email address/or fax number
example@example.com
Curana Health 8911 N. Capital of Texas Hwy., Building 1 Ste #1110 Austin, TX.78759

Phone: 877-279-5960 Fax: 855-916-1997
AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

This request and authorization applies to healthcare information relating to the following treatment, condition, & dates of service for (list below the type of records being requested
This request and authorization applies to healthcare information relating to the following treatment condition dates of service for list below the type of records being requested and dates of records
I authorize the release of any records regarding drug, alcohol, or mental health treatment to Curana Health.

YesNo
This authorization may not be valid for greater than one year from the date of signature. I understand that after the custodian of records discloses my health information, it may no longer be protected by federal privacy laws. I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my ability to obtain treatment; receive payment; or eligibility for benefits unless allowed by law. By signing below I represent and warrant that I have authority to sign this document and authorize the use or disclosure of protected health information and that there are no claims or orders pending or in effect that would prohibit, limit, or otherwise restrict my ability to authorize the use or disclosure of this protected health information.
Patient/DPOA/Guardian Signature

Clear
Date

MonthDayYear
Date
Prior to your first visit with a Curana Health provider, please obtain the most recent clinic visit notes and most recent lab results from your previous providers, if possible.
New Patient Health History
Patient Name*
Date of Birth*

MonthDayYear
Date
Patient Address
Phone Number
Current Height
Current Weight
Previous Primary Care Provider
Other Specialists Foot/Eye/Kidney/Heart/Diabetes/Bladder/Cancer,Etc
HEALTH INSURANCE
Attach or provide photocopy of health insurance card(s
Insurance Provider*
Policyholder Name*
Policy Identification Number*
Group Number If Applicable
NEW PATIENT HEALTH HISTORY
SECONDARY INSURANCE (IF APPLICABLE)
Insurance Provider
Policyholder Name
Policy Identification Number
Group Number If Applicable
PAST MEDICAL HISTORY (Please Check All That Apply):
PAST MEDICAL HISTORY

Acid RefluxAlcohol UseAmputationAnemiaAtria FibrillationCancerDementiaDepression/AnxietyBipolar DisorderDiabetes Type 1 or 2Drug AbuseGlaucomaHeart Disease/FailureHepatitisHigh CholesterolHIV/AIDSHigh Blood PressureInsomniaLung Disease/COPDAsthmaBowel DiseaseCrohn's Kidney DiseaseMigrainesMultiple SclerosisObstructive Sleep ApneaOsteoporosisParkinson's DiseasePacemaker/DefibrillatorPeripheral Vascular DiseaseRheumatoid ArthritisSchizophreniaSeizuresStrokeThyroid ProblemsOther
Please list any prior hospitalizations andor major surgeries within the last year
Please list any drug food latex or other allergies you have
Pharmacy Name
Pharmacy Phone
Pharmacy Address
Please list any medications or supplements you are taking in the chart below:
Medication Supplement/Dosage/How Often?
FAMILY HISTORY
Mother (Medical Problems, Age, Cause Of Death):
Father (Medical Problems, Age, Cause Of Death):
Brother(s) (Medical Problems, Age, Cause Of Death):
Sister(s) (Medical Problems, Age, Cause Of Death):
SOCIAL HISTORY
Current smoker?

YesNoIf "yes", how much and how often?
Past smoker?

YesNoIf "yes", when did you quit?
Current smokeless tobacco or e-cig user?

YesNoIf "yes", how much and how often?
Past smokeless tobacco or e-cig user?

YesNoIf "yes", when did you quit?
Drink alcohol?

YesNoIf "yes", how much and how often?
Date of last drink?
NEW PATIENT HEALTH HISTORY
Do you currently or have you ever used any recreational drugs?

YesNo
If "yes" what types?
Date of last use

MonthDayYear
Date
Have you ever received treatment for alcohol or drug use?

YesNo
Do you exercise?

YesNo
How many times per week?
How much caffeine coffee or soda do you drink per day
Do you have trouble sleeping?

YesNo
Do you take any sleep aids?

YesNo
If so, what kind?
ACTIVITIES OF DAILY LIVING
Do you live alone?

YesNo
Do you use portable oxygen?

YesNo
Do you need help with daily activities?

YesNo
Have you had any falls in the last 12 months?

YesNo
If yes, how many?
Do you use a cane?

YesNo
A walker?

YesNo
A wheelchair?

YesNo
Hearing aid(s)?

YesNo
PLEASE LIST DATES OF PREVIOUS SCREENINGS (AND RESULTS IF KNOWN):
Cholesterol screening
Hepatitis C screening
Eye exam
Mammogram
Stoolbased test (FIT, FOBT)
Colonoscopy
PLEASE PROVIDE THE DATE OF ANY IMMUNIZATIONS AND VACCINES YOU HAVE RECEIVED:
Pneumococcal vaccine
Tetanus
Influenza
Shingles vaccine
COVID19 vaccine
Do you have a living will and/or healthcare proxy?
Power of Attorney (Name and Phone Number)
ADVANCE CARE PLANNING ACP
Attach or provide a photocopy of signed Advanced Directive documents.

DNRFull Code
IS THERE ANY OTHER INFORMATION YOU WOULD LIKE YOUR CURANA HEALTH PROVIDER TO KNOW?
Should be Empty:

CURANA HEALTH Consent to Treat

Protected Health Information

ORAL COMMUNICATION

WRITTEN COMMUNICATION

OTHER COMMUNICATION

Authorization To Release Healthcare Information To Curana Health

New Patient Health History

HEALTH INSURANCE

NEW PATIENT HEALTH HISTORY

SECONDARY INSURANCE (IF APPLICABLE)

FAMILY HISTORY

SOCIAL HISTORY

NEW PATIENT HEALTH HISTORY

ACTIVITIES OF DAILY LIVING

PLEASE LIST DATES OF PREVIOUS SCREENINGS (AND RESULTS IF KNOWN):

PLEASE PROVIDE THE DATE OF ANY IMMUNIZATIONS AND VACCINES YOU HAVE RECEIVED:

ADVANCE CARE PLANNING ACP