Healthcare Authorization and Consent Form

HEALTHCARE AUTHORIZATION AND CONSENT FORM

Patient Information

Patient Name:     Date of Birth:     Gender:

Phone:     Email:

Insurance Information

Policy Number:     Group Number:

Medical History (Relevant)

Authorization for Treatment and Procedures

I, the undersigned, authorize the medical providers and staff of the treating facility to perform the following procedure(s) and to provide such diagnostic and therapeutic treatment as may be necessary and reasonable in the judgment of the treating clinician:

I understand that no guarantee has been made to me as to the results of any procedure or treatment. I acknowledge that the clinician has explained the nature, purpose, expected benefits and material risks of the proposed procedure, which may include but are not limited to: infection, bleeding, blood clots, allergic reaction, organ or nerve injury, need for additional procedures, prolonged recovery, and death. I have had the opportunity to ask questions and those questions have been answered to my satisfaction.

I authorize administration of medications and anesthesia as deemed appropriate. I further authorize such additional procedures as may be necessary in the event of an unforeseen condition discovered during the procedure. I understand and accept the inherent risks associated with the proposed care.

I consent to the proposed treatment/procedure. I consent to administration of anesthesia/sedation as required. I consent to clinical photography/video for treatment or documentation. I consent to necessary laboratory or diagnostic tests.

Authorization to Release Protected Health Information (PHI)

I authorize the release and disclosure of my protected health information as necessary for treatment, payment, and healthcare operations to the entities and persons listed below and for the purposes indicated. This authorization includes information relating to medical history, diagnostic tests, treatment records, and billing records. Sensitive information, including substance abuse treatment records and mental health records, will be released only if expressly indicated below.

Medical records and clinical notes   Billing and insurance records   Laboratory and imaging results   Mental health records (except psychotherapy notes)   Substance use treatment records (42 CFR protected)

I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by applicable privacy laws. I understand that I may refuse to sign this authorization and that my refusal will not affect my ability to obtain treatment, except where the ability to obtain treatment is conditioned on execution of this authorization.

This authorization may be revoked at any time by providing written notice to the treating facility, except to the extent that action has been taken in reliance on this authorization. Any revocation will not affect disclosures already made in reliance on this authorization prior to receipt of the revocation.

Patient Acknowledgment and Certification

By signing below I certify that the information I have provided is true and complete to the best of my knowledge. I acknowledge that I have read and understood the foregoing statements, that I have had the opportunity to ask questions about my treatment and the release of my health information, and that those questions have been answered to my satisfaction. I understand I may request a copy of this signed authorization.

I further authorize assignment of benefits to the treating provider and authorize the release of information necessary to process claims for payment. I accept financial responsibility for services not covered by insurance.

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