Intake Paperwork – LifeSpring Health Systems

Date
MM slash DD slash YYYY
Patient Name*
First Last
Name of Person Completing Form (if different than patient)
First Last
Patient Date of Birth
Month
Day
Year
Address (mark N/A if the patient is not housed)*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
What is your County of Residence?
Phone*
Email
Patient's Marital Status
Patient's Race
Ethnicity
Gender Identity
Sexual Orientation
Sex at birth*
- Male
- Female
- Undefined
Employer or School Information
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insurance Company
Insurance Policy Number
Name and Date of Birth of Policy Holder
Veteran Status
Education
Agricultural Work Status
Citizenship
Housing Status
Emergency Contact Name
First Last
Emergency Contact Phone
Emergency Contact Relationship
Referral Source*
What Service Would You Like To Schedule An Appointment For? (Select One or Both)
- Medical Care
- Behavioral Health Care
Please briefly describe the issue you are having or what you would like to be seen for.*

I the undersigned do hereby consent to diagnostic and treatment procedures deemed necessary by the clinical/medical staff of LifeSpring Health Systems.*
I hereby consent to treatment.
I understand that the cost of any special services, such as special medication, emergency medical transportation, physician office calls, dental visits, etc. will be my personal responsibility.*
I understand costs not covered by insurance will be my responsibility.
I hereby relieve LifeSpring/Turning Point Center of any liability from injury/illness which may result from group recreational activities as conducted off the LifeSpring premises.*
I release LifeSpring from liability for injury.
I authorize LifeSpring to release copies of any of my medical records and or financial information necessary to file any client for payment of my account by any health, sickness or accident insurance company, or in connection with worker’s compensation, to others responsible for insurance claims and investigations, upon presentation to LifeSpring of reasonable evidence that said carrier has in effect a policy or policies covering my healthcare services. I understand that this release will include but not be limited to the following (1) Diagnosis, (2) Admission history to include family, social and psychiatric/medical history, (3) Discharge Summary to include dates or treatment, outcome of treatment, prognosis, response to treatment, (4) Physical examination, (5) Laboratory and x-ray reports, (6) and drug/alcohol information.*
I consent to the release of records.
I understand and agree that I (the patient) am responsible for any eligible, accumulated charges/balance not covered and/or paid by insurance or other third party payor. This includes co-payments, deductibles, and usual and customary allowances. It is further agreed that, in the event legal action is required in order to enforce payment of this account, I (the patient) will pay all court costs, expenses, attorney’s fees and other costs incurred and/or expended as a result of such proceedings.*
I understand I am responsible for all charges not reimbursed.
I (the patient) authorize payment directly to LifeSpring of the medical benefits, if any, otherwise payable to me for LifeSpring’s services as described but not to exceed the reasonable and customary charge for these services.*
I authorize payment.
Your signature below will authorize LifeSpring Health Systems to send Appointment Reminders electronically via text message to your mobile phone. If you do not have a mobile phone, we can electronically remind you of your appointments on a landline via phone call/voicemail.*
I consent to electronic reminders.

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