Healthcare CAS Document

Clinical Assessment and Authorization for Services (CAS Document)

Patient Information

Patient Name:     Date of Birth:

Emergency Contact

Insurance Information

Medical History

Clinical Assessment & Recommended Services

Clinician:     Facility:

Risks, Benefits, Alternatives

The clinician has explained the nature of the recommended services, expected benefits, common and material risks, and reasonable alternatives including the option of no treatment. Patient acknowledges that no guarantee has been made as to outcome. Patient understands that complications, adverse reactions, or incomplete resolution of symptoms may occur and that follow-up care may be required.

Authorizations & Acknowledgements

By checking the boxes below and signing this document, the patient (or legal representative) provides the following authorizations and acknowledgements:

  I consent to the recommended evaluation, diagnostic testing, and treatment as described above and to any routine or ancillary care reasonably required in the course of treatment.

  I authorize my insurance benefits to be paid directly to the treating provider and authorize release of medical information necessary to process claims. I accept financial responsibility for services not covered by insurance.

  I authorize disclosure of my protected health information to the entities necessary for treatment, payment and healthcare operations. I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance upon it.

Patient rights: The patient has the right to ask questions, request clarification, and refuse or withdraw consent at any time. Withdrawal of consent will not affect care provided for conditions already treated and may have implications for ongoing treatment.

Release for Photographs / Recordings (Optional)

  I authorize clinical photographs, videos, or audio recordings for treatment, documentation and internal quality review. I understand that identifiable images or recordings will not be used for educational or promotional purposes without separate written consent.

Patient Certification

I certify that the information I have provided on this form is complete and accurate to the best of my knowledge. I have had the opportunity to ask questions about the assessment, recommended services, risks, benefits, alternatives, and anticipated outcomes. I understand my obligations regarding payment and insurance assignment as set forth above.

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