Healthcare Caregiver Consent Form

Healthcare Caregiver Consent Form

Patient Information

Date of Birth:    Gender: Male Female Non-binary

Caregiver Information

Authorization Start Date:    Authorization Expiration Date:

Caregiver Designation: Primary caregiver Temporary caregiver

Insurance Information

Medical History (Relevant)

Authorization and Consent

I, the undersigned patient or authorized guardian, hereby designate the named caregiver to act on my behalf with respect to my health care and administrative needs as set forth below. This authorization is limited to the permissions expressly checked and does not otherwise create a power of attorney unless separate legal documentation is executed.

Permissions (check all that apply)

Access and receive copies of medical records and protected health information necessary for my care, including test results and progress notes.

Communicate with my health care providers regarding diagnosis, treatment plans, medication changes, and appointment scheduling.

Pick up prescriptions, medical supplies, and necessary medications on my behalf.

Transport me to and from medical appointments and related activities.

Provide consent for routine, non-invasive medical or nursing care that is customarily delegated to caregivers (e.g., wound care, routine immunizations) when I am unavailable to consent personally.

Access billing, insurance, and payment information related to my care and communicate with financial services regarding my account.

In the event I am incapacitated and unable to communicate, make urgent health care decisions consistent with accepted clinical practice and in my best interest, to the extent permitted by law.

Limitations and Conditions

This authorization does not authorize the caregiver to make decisions that require a legal guardian, health care proxy, or power of attorney unless such documentation is separately executed and attached to this form. The caregiver may not authorize major surgical procedures, sedation, or experimental treatments on my behalf without my prior written consent or separate legal authority.

HIPAA Authorization / Privacy Acknowledgment

I authorize my health care providers and health plan to disclose protected health information (PHI) to the designated caregiver to the extent necessary to carry out the permissions indicated above. I understand that information disclosed pursuant to this authorization may include sensitive medical information and that once disclosed, it may be subject to re-disclosure by the recipient and no longer protected by federal privacy regulations.

I understand I may revoke this authorization at any time by providing written notice to my health care provider. Revocation will not affect disclosures already made in reliance upon this authorization prior to receipt of the revocation. This authorization will automatically expire on the Authorization Expiration Date above unless revoked earlier in writing.

Acknowledgment

By signing below I acknowledge that I have read and understand the terms of this Caregiver Consent Form, that I am the patient or am authorized to sign on behalf of the patient, and that I authorize the release of my PHI and the actions described herein to the designated caregiver.

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