Healthcare AFICS FIRE ATR

Healthcare AFICS FIRE ATR

This Healthcare AFICS FIRE ATR (Acute Fire Incident Care and Treatment Authorization and Release) documents patient identity, incident circumstances, emergency treatment, authorization for continuing care and release of protected health information related to a fire-related incident. Patient Name: Date of Birth: Medical Record / ID:

Patient Information

Insurance Information

Incident & Triage Details

Incident Date: Time: Location:

Treatment Provided On Scene

Medical History / Current Status

Consent for Emergency and Follow-up Treatment

I authorize medical personnel to provide evaluation, necessary emergency care, stabilization, and transfer to an appropriate facility related to injuries or exposure sustained in the fire incident described above. I understand and agree that reasonable attempts will be made to explain treatments when possible, but treatment may be rendered without delay when necessary to preserve life or prevent serious deterioration. I understand risks of treatment may include but are not limited to infection, allergic reaction, airway complications, scarring, and other risks inherent to each intervention. I have been provided an opportunity to ask questions and have those questions answered to my satisfaction.

I understand that I have the right to withdraw this consent to the extent permitted by law and that withdrawal will be documented in my medical record. Withdrawal of consent will not affect care already provided or obligations of the medical provider to stabilize and treat in emergency circumstances.

Authorization to Release Protected Health Information (PHI)

I authorize the release of my protected health information related to this fire incident to the following recipient for purposes of continuing care, insurance billing, and incident investigation: Recipient Name:

This authorization is voluntary and will remain in effect until: or until the purpose for release is fulfilled, whichever occurs first. I understand I may revoke this authorization in writing except to the extent action has already been taken in reliance on it.

Financial Responsibility & Assignment

I authorize assignment of benefits to the provider for services rendered and agree to be responsible for charges not covered by insurance. I certify that the information provided on this form is true and complete to the best of my knowledge and understand that falsification may affect insurance claims and could result in liability for costs of care.

Patient Certification

By signing below I certify that I am the patient or have legal authority to act on behalf of the patient (for minors or incapacitated individuals). I certify the information supplied on this form is accurate and that I understand the consents, authorizations, and acknowledgements contained herein. I consent to release and share my medical information as stated for the purposes indicated.

Sign Now