Healthcare ASC Form

Healthcare ASC Form

Patient Information

Patient Name:    Date of Birth:    Gender:

Insurance & Billing

Medical History

Do you smoke or use tobacco?   Yes    No

Procedure & Anesthesia

Type of anesthesia proposed: Local Sedation Regional General

I authorize the Ambulatory Surgery Center, its physicians, nurses and aides to provide such treatment as deemed necessary or advisable in connection with the above described procedure. I understand that no guarantee has been made as to the results that may be obtained.

Risks, Alternatives, & Rights

The undersigned acknowledges that the nature, purpose, and expected outcomes of the proposed procedure and anesthesia have been explained. The known risks and complications, which may be significant and could include infection, bleeding, nerve damage, scarring, adverse reaction to anesthesia, need for conversion to inpatient care, and death, have been explained. Alternatives to the procedure, including non-surgical options and reasonable risks of those alternatives, have been discussed.

I understand that I have the right to ask questions and to withdraw consent at any time prior to initiation of the procedure. Withdrawal of consent after initiation of anesthesia or the procedure may not be possible; I acknowledge that the physician will advise me regarding the safest course of action.

In the event of an emergency during the procedure, I consent to such additional procedures as are deemed necessary by the attending physician for my safety.

Blood Products

If the need arises for blood transfusion or blood products, I consent to the administration of such blood products, unless I have indicated a specific refusal below.

I refuse blood transfusion or blood products.

HIPAA Privacy & Release Authorization

I acknowledge receipt of the ASC's Notice of Privacy Practices and understand my rights regarding my protected health information. I authorize the release of my medical information, including diagnosis, treatment, and operative reports, to the persons or entities identified below for the purpose of continuity of care, billing, and insurance processing.

Financial Responsibility & Assignment

I certify that the information given about insurance coverage is accurate to the best of my knowledge. I authorize payment of medical benefits to the Ambulatory Surgery Center for services rendered. I agree to be financially responsible for charges not covered by insurance, including co-payments, deductibles, and services denied by my insurer.

I authorize the ASC and its billing agents to submit claims, appeal claims, and provide any necessary information to my insurer(s). I understand that I remain ultimately responsible for payment of my account.

Photographs / Recordings

I grant permission for photographic, video, or digital images to be taken as necessary for medical records, identification, treatment documentation, or quality improvement. I understand images used for education or publication will not include identifying information unless additional specific consent is obtained.

I do not consent to the taking of images for any purpose beyond medical record documentation.

Acknowledgments & Certifications

By signing below I certify that I have read and understand the information contained in this form, that I have had the opportunity to ask questions, that all of my questions have been answered to my satisfaction, and that I consent to the procedures and treatments described herein. I understand that this consent will remain in effect unless I revoke it in writing.

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