Clinical Intake Form Template for United States

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Key Requirements PROMPT example:

Clinical Intake Form

"Need a Clinical Intake Form for a new mental health practice opening in March 2025, with specific sections for substance abuse screening and telemedicine consent, compliant with California state regulations."

Document background

The Clinical Intake Form is a fundamental document in U.S. healthcare settings, designed to gather comprehensive patient information at the first point of contact. It serves multiple purposes: establishing the patient-provider relationship, documenting medical history, ensuring regulatory compliance, and facilitating proper billing procedures. This document must comply with HIPAA regulations, state-specific healthcare laws, and other relevant federal regulations. The form typically includes sections for patient demographics, insurance information, medical history, and various required consents, creating a foundation for the patient's medical record and treatment plan.

Suggested Sections

1. Patient Demographics: Basic identifying information including name, date of birth, address, contact details, emergency contacts, and preferred language

2. Insurance Information: Primary and secondary insurance details, policy numbers, group numbers, and policyholder information

3. Medical History: Current medical conditions, past surgeries, medications, allergies, family medical history, and immunization records

4. Consent for Treatment: Patient authorization for medical care and acknowledgment of treatment terms

5. Privacy Notice Acknowledgment: HIPAA acknowledgment and consent for use and disclosure of protected health information

Optional Sections

1. Substance Use History: Details about current and past substance use, treatment history, and related medical conditions - for use in behavioral health or addiction treatment settings

2. Mental Health Screening: Assessment of mental health status, previous psychiatric treatment, and current symptoms - for use in psychiatric or behavioral health intake

3. Social History: Information about family structure, work situation, living arrangements, and support systems - for use in comprehensive care planning

Suggested Schedules

1. Notice of Privacy Practices: Detailed explanation of HIPAA privacy rules and patient rights regarding protected health information

2. Patient Rights and Responsibilities: Comprehensive list of patient rights and obligations under treatment

3. Financial Policy: Detailed explanation of payment terms, insurance billing procedures, and financial responsibilities

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Healthcare
Mental Health
Rehabilitation
Specialized Medicine

Relevant Teams

Medical Records
Front Office
Compliance
Legal
Information Technology

Relevant Roles

Medical Director
Practice Manager
Intake Coordinator
Compliance Officer
Medical Records Manager

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Electronic Intake Forms

Legal framework for electronic intake forms compliant with US federal and state regulations, governing digital information collection and processing.

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Authors

Alex Denne

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