Healthcare Consumer Consent Form

HEALTHCARE CONSUMER CONSENT FORM

Patient Information

Date of Birth:

Female    Male    Other    Prefer not to say

Insurance Information

Medical History

Consent for Treatment and Authorization

I, the undersigned, hereby authorize and consent to such medical examination, diagnostic procedures, laboratory testing, immunizations, medical treatment, and surgical procedures as may be considered necessary or advisable by the attending healthcare professionals. I understand that all treatments carry risks and that no guarantees have been made to me regarding the results of any examination or treatment.

Risks, benefits, and alternatives have been explained to me and I have had an opportunity to ask questions. I acknowledge that I may refuse or withdraw consent at any time by providing written notice, except to the extent that action has already been taken in reliance on this consent. I understand that emergency treatment necessary to prevent serious harm may be provided regardless of this consent in accordance with applicable law.

I accept financial responsibility for services rendered. I authorize the release of medical information necessary for billing and payment purposes to my insurer and to other health care providers for continuity of care. I understand that this authorization remains in effect until revoked in writing, but that revocation will not affect disclosures made in reliance upon this authorization prior to notification of revocation.

Authorization for Release of Protected Health Information (PHI)

I authorize the healthcare provider and its agents to use and disclose my protected health information for purposes of treatment, payment, and healthcare operations as permitted by law. This authorization includes verbal, written and electronic PHI, and may include mental health, substance use disorder, HIV-related, and genetic information where permitted by law.

I specifically authorize release of my PHI to the following individual(s) or entity(ies):

This authorization will expire on:   or upon written revocation.

HIPAA Privacy Acknowledgment

I acknowledge that I have been provided with or offered the provider's Notice of Privacy Practices describing how my protected health information may be used and disclosed, and what my rights are with respect to that information. I understand that I may request restrictions on certain uses and disclosures and that the provider may refuse to agree to such restrictions under certain circumstances.

I acknowledge receipt of the Notice of Privacy Practices or that it was made available to me.

Additional Consents and Notices

Telehealth: I understand that certain services may be provided via telehealth means. I consent to such services when offered and understand associated limitations and risks. I may revoke consent to telehealth in writing, except to the extent services have already been provided.

Interpreter Services: Interpreter required?   Yes   No

If yes, language requested:

Consent Certification

By signing below I certify that I am the patient or, if signing on behalf of the patient, that I am the patient's legal guardian or authorized representative. I have read and understand the information provided in this form, all of my questions have been answered to my satisfaction, and I consent to the treatment and authorizations described above.

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