Healthcare Anesthesia Authorization

HEALTHCARE ANESTHESIA AUTHORIZATION

Patient Information

Date of Birth:    Gender:

Phone:    Email:

Relationship:    Phone:

Insurance / Billing

Policy Number:    Group Number:

Procedure & Anesthesia Plan

Surgeon / Proceduralist:    Facility:

Scheduled Date:    Estimated Duration:

General anesthesia    Regional anesthesia (e.g. nerve block)    Spinal / Epidural    Monitored anesthesia care (MAC)    Local anesthesia   

Medical History & Preoperative Information

Chronic Medical Conditions:

Bleeding disorder or anticoagulant use?    Yes    No

Are you pregnant or is there a possibility you are pregnant?    Yes    No

Risks, Benefits and Alternatives

The anesthesiologist has explained to me the nature and purpose of the proposed anesthesia and related procedures, including likely benefits, material risks, and reasonable alternatives. Common risks include nausea, vomiting, sore throat, temporary confusion, and discomfort. Rare but serious risks include aspiration, airway difficulties, allergic reactions, myocardial infarction, stroke, brain injury, permanent neurological injury, and death. Regional techniques may cause nerve injury, infection, or bleeding. I understand that no guarantee can be made that anesthesia will be entirely without risk.

I acknowledge that the benefits of anesthesia include facilitation of a pain-free procedure, patient comfort, and improved procedural conditions. Reasonable alternatives, when applicable, include performing the procedure with local anesthesia alone, regional techniques, sedation-only, or postponement. I have had the opportunity to ask questions and understand the information provided.

I consent to the administration of medications, fluids, blood products if deemed necessary for my immediate care, and any monitoring and procedures routinely performed in anesthesia practice, including airway management and vascular access.

I authorize the administration of blood and blood products if medically necessary:    Yes    No

Authorization, HIPAA & Patient Rights

I voluntarily authorize the anesthesiologist and other qualified clinicians to perform anesthesia and related procedures for the purposes described above. I authorize the release of pertinent medical information to personnel involved in my care and to my insurance carrier for billing and payment purposes. This authorization includes disclosure of protected health information necessary for anesthesia care and billing.

I understand that I may revoke this authorization in writing at any time, except that revocation will not affect any action taken in reliance on this authorization prior to receipt of the revocation. I understand that if I do not sign this form, anesthesia and the procedure may be delayed or cancelled.

Authorization Expiration Date (if applicable):

I acknowledge receipt of the anesthesia information and privacy practices as presented to me and affirm that my questions, if any, have been answered to my satisfaction. I understand I may withdraw consent before administration of anesthesia.

Patient Attestation

I attest that the information I have provided on this form is true and complete to the best of my knowledge. I acknowledge that I have had the opportunity to discuss anesthesia options, risks, benefits, and alternatives with a member of the anesthesia team.

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