Healthcare CWO Document

HEALTHCARE CLINICAL WORK ORDER & CONSENT (CWO)

Ordering Facility / Provider

Facility / Clinic Name:

Ordering Provider:   NPI / ID:

Order Date:

Patient Information

Insurance Information

Clinical Order / Procedure Details

Procedure / Service Requested:

Priority / Timing: Routine Urgent Stat

Medical History & Current Status

Risks, Benefits, and Alternatives

I acknowledge that the proposed procedure has been explained to me, including its intended benefits and reasonably foreseeable risks. Typical risks include, but are not limited to: infection, bleeding, pain, scarring, allergic reaction, failure to achieve the desired outcome, need for additional procedures, anesthesia-related complications, and unforeseen complications requiring hospitalization. No guarantee has been made regarding the results of the procedure.

Reasonable alternative treatments, including no treatment, and the risks and benefits of those alternatives have been discussed with me. I have had the opportunity to ask questions and have received answers in terms I understand.

Consent and Authorization

By signing this document, I authorize the Ordering Provider and associated clinical staff to perform the procedure(s) and related diagnostic or therapeutic interventions specified above. I authorize performance of any additional procedures that, in the professional judgment of the provider, are necessary for my immediate care if unforeseen conditions arise during the procedure.

I understand that I may withdraw this consent at any time prior to the initiation of the procedure by notifying the Ordering Provider or facility in writing or verbally. Withdrawal of consent will not affect actions taken prior to receipt of such notice.

HIPAA / Release of Information Authorization

I authorize the release of my protected health information (PHI) related to the procedure described herein to the insurance carriers, other treating providers, and entities involved in claims adjudication and quality review. This authorization includes records of evaluation, treatment, and diagnostic testing relevant to this order.

This authorization will remain in effect until:  or until revoked in writing by the patient or authorized representative. Revocation will not apply to information already released in reliance on this authorization.

Acknowledgement: I acknowledge receipt of the facility's privacy practices and consent to use and disclosure of my PHI as described above.

Billing and Financial Responsibility

I understand that charges for services rendered will be submitted to my insurance carrier when appropriate. I accept financial responsibility for any fees not covered by insurance, including co-payments, deductibles, and services determined by the insurer to be non-covered. Questions regarding billing should be directed to the facility billing office.

Patient Certification

I certify that I have read and understand the information on this form, that the information I have provided is accurate, and that I have had the opportunity to ask questions which were answered to my satisfaction. I consent to the performance of the described procedures and to the release of my health information as set forth above.

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