Healthcare Consent Packet

Healthcare Consent Packet

Patient Information

Date of Birth:    Gender:

Emergency Contact & Provider

Relationship:    Phone:

Insurance Information

Policy/ID #:    Group #:

Medical History

Female patients: Pregnant or possibly pregnant? Yes

Procedure / Treatment Authorization

I hereby authorize licensed practitioners, their assistants and other healthcare personnel to perform the procedure(s) described above and such other procedures as are necessary and advisable in the course of my treatment. I understand that no guarantee has been made as to the results that may be obtained.

The nature and purpose of the recommended treatment, the expected benefits, material risks, possible complications and reasonable alternatives (including no treatment) have been explained to me in terms I understand. I have had the opportunity to ask questions and all my questions have been answered to my satisfaction.

I acknowledge receipt of the foregoing explanation and voluntarily consent to the proposed treatment. I understand I may withdraw this consent at any time prior to the procedure by notifying my treating clinician; withdrawal will not affect actions already taken in reliance on this consent.

I acknowledge that risks, benefits and alternatives have been explained and I consent to the proposed treatment.

I consent to administration of anesthesia or sedation as deemed necessary by the provider, including local, regional or general anesthesia. I understand specific anesthesia risks have been explained.

I consent to blood transfusion or blood products if medically necessary and if no suitable alternatives are available.

I consent to photography, video or other imaging for clinical documentation, education or treatment planning. I understand images will be treated as protected health information.

I consent to telemedicine or remote consultations where appropriate and understand limitations related to remote care.

HIPAA Authorization & Privacy Acknowledgment

I authorize the use and disclosure of my protected health information (PHI) as reasonably necessary for treatment, payment, healthcare operations and coordination of care. This includes verbal, written and electronic communications. I acknowledge I have been provided with the facility's privacy practices and that I may request restrictions on certain uses and disclosures, which the facility will attempt to honor consistent with applicable law.

I acknowledge the privacy practices and authorize release of my PHI for treatment, payment and healthcare operations.

Release of Medical Records

I authorize release of my medical records and relevant health information to the persons or entities identified below for the purpose of continuity of care, insurance claims, or legal purposes as necessary.

I authorize release of my records as indicated above.

Billing / Assignment of Benefits

I authorize assignment of insurance benefits and direct payment to the treating facility or provider for services rendered. I understand I am financially responsible for charges not covered by my insurance.

I authorize billing and assignment of benefits to my health insurer(s).

Revocation; Minor / Guardian Certification

I understand I may revoke this authorization at any time in writing, except to the extent that actions have already been taken in reliance upon this authorization. If the patient is a minor or otherwise legally incapable of consenting, the undersigned certifies that they are the patient's parent or legal guardian and have the legal authority to execute this consent.

By signing below I certify that the information provided is true and complete to the best of my knowledge; I have had the opportunity to ask questions; and I consent to the treatments and authorizations checked above.

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