Healthcare Consent Agreement

HEALTHCARE CONSENT AGREEMENT

Patient Name:    Medical Facility:    Attending Physician:

Patient Information

Male   Female   Other   Prefer not to say

Insurance Information

Medical History

Procedure / Treatment Details

Scheduled Date:    Estimated Duration:

Local   Regional   General   Monitored Sedation   No anesthesia planned

Blood Transfusion: I consent to blood products if deemed medically necessary    I decline blood transfusion

Risks, Benefits, and Alternatives

The physician has explained to me the nature and purpose of the proposed procedure or treatment, the significant known risks and probable benefits, and the reasonable alternatives including the option of no treatment. Known risks may include, without limitation, infection, bleeding, scarring, adverse reaction to medications or anesthesia, persistent symptoms, disability, or death. I understand that no guarantee can be made concerning the results of the procedure.

I acknowledge that the risks, benefits, and alternatives have been explained to my satisfaction and that I have had the opportunity to ask questions and receive answers. I voluntarily consent to the performance of the procedure described above and to any additional or alternative procedures that, in the physician's professional judgment, are necessary or advisable during the course of treatment.

I acknowledge that these matters were discussed and I give consent for the procedure described.

Right to Withdraw

I understand that I have the right to revoke this consent at any time prior to the performance of the procedure by notifying the attending physician or a member of the treating team. Revocation will not affect any actions already taken based on this consent.

I understand my right to withdraw consent prior to treatment.

HIPAA / Privacy Authorization

I authorize the release of my protected health information to persons and entities involved in my care and for billing and payment purposes as required for treatment, payment, and health care operations. I understand that information disclosed under this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy law.

I acknowledge receipt of the facility's privacy practices and consent to the disclosure described above.

Certification and Consent

By signing below I certify that I am the patient or am authorized to sign as the patient's personal representative. I certify that I understand the information provided to me, that all blank spaces on this form were completed prior to my signing, and that my consent is given voluntarily. I have had the opportunity to ask questions and all questions have been answered to my satisfaction. I consent to the treatment described above and to such diagnostic and therapeutic procedures as may be necessary or advisable in the physician's judgment.

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