Healthcare Consent and Lease Form

HEALTHCARE CONSENT AND LEASE FORM

Patient Information

Date of Birth:    Gender: Male Female Other

Phone:    Email:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy Number:    Group Number:

Medical History

Consent to Treatment

I, the undersigned patient or legal representative, hereby authorize and consent to the provision of medical care, diagnostic procedures and treatment as deemed necessary by licensed healthcare providers associated with the facility. I acknowledge that such treatment may include examination, administration of medication, use of medical equipment, and other customary services related to the scope of care.

I understand that all medical procedures carry risks, including but not limited to infection, bleeding, allergic reaction to medications or materials, and unforeseen complications. The attending clinician has explained the material risks, anticipated benefits, and reasonable alternatives. I have had the opportunity to ask questions and those questions have been answered to my satisfaction.

I voluntarily consent to the treatment described above and authorize the providers to proceed.

Lease of Medical Equipment / Facility Space

The undersigned leases from the facility the equipment and/or designated space identified below under the terms set forth in this section. This lease is ancillary to the provision of medical services and is governed by the terms specified herein.

Lease Commencement:    Lease Term (months):

Monthly Lease Amount: $    Security Deposit: $

The lessee agrees to maintain the leased equipment in good working order, to return it in substantially the same condition as received, reasonable wear and tear excepted, and to notify the lessor promptly of any malfunction. The lessee shall be responsible for repair or replacement costs resulting from misuse or negligence. The lessor shall retain the right to inspect equipment and perform necessary maintenance with reasonable notice.

Termination: Either party may terminate this lease for material breach following written notice and a reasonable cure period of thirty (30) days. In the event of early termination by the lessee without cause, lessee remains liable for unpaid lease payments per the remaining term unless otherwise agreed in writing.

Financial Responsibility; Insurance

The patient or responsible party acknowledges financial responsibility for charges not covered by insurance, including lease charges, deductibles, co-payments, and costs arising from damage to leased equipment. Lessee is encouraged to maintain insurance covering leased equipment and agrees to provide proof of such insurance upon request.

HIPAA Authorization and Privacy Acknowledgment

I acknowledge receipt of the facility's privacy practices and understand that my protected health information may be used and disclosed for treatment, payment and healthcare operations as described in that notice. I authorize the facility to disclose my health information as reasonably necessary for billing, insurance claims, treatment coordination, and management of leased equipment.

Expiration of Authorization:    If no date specified, this authorization expires one year from the date signed.

I understand I may revoke this authorization at any time by notifying the facility in writing, except to the extent that action has already been taken in reliance on this authorization. I also understand that disclosures made pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations.

Liability, Indemnification and Miscellaneous

To the maximum extent permitted by law, the facility and its staff shall not be liable for indirect, incidental or consequential damages arising from the use of leased equipment or services. The patient agrees to indemnify and hold harmless the facility, its employees and agents from claims arising out of the negligence or misuse of leased equipment by the patient or third parties acting at the patient's direction.

This Consent and Lease Form constitutes the entire agreement between the parties concerning the subject matter herein and supersedes prior agreements and understandings, whether written or oral. Any amendment must be in writing and signed by both parties.

Acknowledgment and Certification

By signing below I certify that I have read and understood this Consent and Lease Form, that the information provided is true and correct to the best of my knowledge, and that I have had the opportunity to ask questions and receive satisfactory answers. I understand my rights and obligations under this agreement.

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