Healthcare Combined Waiver

HEALTHCARE COMBINED WAIVER

Patient Information

Date of Birth:   Gender:

Phone:   Email:

Relationship:   Phone:

Insurance Information

Policy Number:   Group Number:

Medical History

Consent to Treatment and Acknowledgement

I, the undersigned, authorize medical personnel to perform the following procedure(s) or treatment(s):

I acknowledge that no guarantee or assurance has been made to me as to the results that may be obtained. The nature, purpose, benefits, risks and possible complications of the procedure(s) have been explained to me in language I understand. I understand that I have the right to refuse or withdraw consent at any time prior to the procedure, and that withdrawal may not be effective where action has already been taken in reliance on this consent.

Please indicate specific authorizations (check all that apply):

  I authorize general medical treatment related to the described procedure.
  I authorize administration of anesthesia as deemed necessary by the attending provider.
  I authorize blood transfusions if medically indicated.
  I authorize any emergency treatment necessary during the course of care.

Release of Liability and Assumption of Risk

By signing this document I accept and assume the known and unknown risks associated with the proposed treatment. I hereby release, indemnify and hold harmless the facility, its physicians, nurses, employees, agents and representatives from any and all claims, liabilities or causes of action for injury, loss or damage arising from or in connection with the treatment, except for claims resulting from gross negligence or willful misconduct.

Authorization to Obtain and Release Medical Records

I authorize the release of my medical records, including clinical notes, laboratory results, imaging, billing records and other related information to healthcare providers, insurers and their agents for purposes of treatment, payment and healthcare operations. I understand that information disclosed may include records relating to mental health, communicable diseases, HIV-related testing or other sensitive conditions where applicable.

Purpose of disclosure:

This authorization expires on:

HIPAA Privacy Acknowledgment

I acknowledge that I have received or been offered the facility's Notice of Privacy Practices describing how my protected health information may be used and disclosed and my rights with respect to that information. I understand that I may request restrictions on certain uses and disclosures, and that such requests will be considered but are not binding on the facility unless agreed in writing.

  I acknowledge receipt or offer of the Notice of Privacy Practices.

Financial Responsibility and Assignment of Benefits

I agree to be financially responsible for charges not covered by insurance, including co-payments, deductibles and non-covered services. I authorize my insurance benefits to be paid directly to the provider where applicable and permit release of billing information to facilitate payment. I understand that I remain responsible for payment regardless of insurance coverage.

Photograph / Video Release (Optional)

  I consent to the use of photographs, video or audio recordings of me for treatment documentation, education, internal quality improvement or legal purposes. I understand that identifiable images will not be used for promotional or public marketing without a separate written authorization.

Acknowledgement and Certification

By signing below I certify that I have read and fully understand this Healthcare Combined Waiver, that all entries on this form are true and complete to the best of my knowledge, and that I have had the opportunity to ask questions and have received answers to my satisfaction.

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