Healthcare CP ICA

Clinical Procedure Informed Consent and Authorization (CP ICA)

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance Information

Medical History

Do you have any of the following? (check all that apply)

Diabetes    Hypertension    Heart disease    Bleeding disorder

Chronic respiratory disease    Immunosuppression    Implanted medical device (pacemaker, prosthesis)    None of the above

Procedure Information and Consent

Procedure / Treatment to be performed:

Performing Provider:

Scheduled Procedure Date: Month Day Year

Alternatives and No Treatment

Alternatives to the proposed procedure, including the option of no treatment, have been explained and include:

Anesthesia, Sedation and Special Considerations

I understand that anesthesia or sedation may be used when indicated. Possible risks and side effects of anesthesia include, but are not limited to, allergic reaction, nausea, respiratory complications, and, rarely, permanent neurological injury or death.

I have informed the provider of all medications, supplements, and prior adverse reactions to anesthesia:

Authorization to Release Protected Health Information (HIPAA Authorization)

I authorize the release of my protected health information to relevant third parties, including other treating providers, insurance payers, and their agents, as necessary to facilitate treatment, payment, and health care operations related to the procedure described in this document. This authorization is voluntary but required for coordination of care and billing for procedural services.

This authorization will expire on: . If no date is provided, authorization will expire 1 year from the date of signature unless limited by applicable law.

I understand I may revoke this authorization in writing at any time, except to the extent that action has already been taken relying on it.

Photography / Recording Consent

I consent to clinical photography, video, or audio recording for the purpose of medical documentation, diagnosis, treatment planning, or education. I understand identifiable images may be used internally for education or quality assurance unless I mark below to restrict use.

Restrict use of identifiable images for publication or external distribution:

Financial Responsibility and Billing

I understand that I am responsible for payment of services not covered by insurance, including co-payments, deductibles, non-covered services, and any portion denied by my insurer. The provider or facility may bill my insurance carrier as an agent on my behalf.

Voluntary Consent and Certification

By signing below I certify that I have had the nature and purpose of the procedure explained to me, including its benefits, material risks, and alternatives. I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction. I understand that no guarantees have been made to me regarding the outcome of the procedure.

I authorize the provider named above and any assistants to perform the procedure and to take any additional actions that, in the opinion of the provider, are necessary for my health and safety during the procedure.

I understand I may withdraw my consent at any time prior to the initiation of the procedure by informing the provider.

Sign Now