Healthcare Dialysis Agreement

HEALTHCARE DIALYSIS AGREEMENT

This Healthcare Dialysis Agreement documents the informed consent, financial and privacy authorizations, and mutual responsibilities between the Patient and the Dialysis Provider for the provision of dialysis-related services. Patient Name: Medical Facility: Effective Date:

Patient Information

Male    Female    Other / Prefer not to say

Insurance and Billing

Medical History & Current Status

Prescribed Dialysis Treatment Plan

Prescribed Modality: In-Center Hemodialysis   Home Hemodialysis   Peritoneal Dialysis

Arteriovenous Fistula   Graft   Central Venous Catheter

Risks, Benefits, and Alternatives

The Patient has been advised of the benefits of dialysis including removal of toxins and regulation of fluid and electrolytes, and the risks including but not limited to infection, bleeding, hypotension, clotting of access, vascular injury, allergic reaction to dialyzers or medications, need for blood transfusion, and potential for hospitalization or death. Alternatives to the recommended dialysis modality and the option of palliative/non-dialytic management have been discussed.

I acknowledge that I have had the opportunity to ask questions regarding the above risks, benefits, and alternatives and that my questions have been answered to my satisfaction.

Acknowledgement: I acknowledge that the risks, benefits, and alternatives have been explained.

Consent to Treatment and Administrative Authorizations

Consent to Treatment: The Patient authorizes the Dialysis Provider and its agents to perform dialysis treatment, related vascular access care, laboratory testing, administration of dialysis-related medications, and emergency medical care as may be necessary. This includes authorization for blood products or transfusion if ordered by the treating physician when clinically indicated, unless explicitly refused below.

Transfusion Refusal: I refuse blood transfusion except in life-threatening circumstances.

Financial Responsibility and Assignment of Benefits: The Patient agrees to be responsible for all charges for services furnished by the Dialysis Provider that are not paid by insurance or other third-party payers. The Patient assigns to the Dialysis Provider any available insurance or third-party benefits for the purpose of payment and authorizes the release of medical information necessary to process claims. The Provider makes no guarantee of coverage or payment by any insurer.

Collections and Billing: If Patient fails to pay amounts due, the Provider may pursue collection remedies including account assignment to collections and reporting to credit agencies where permitted by law. Patient will notify Provider promptly of changes in insurance coverage.

HIPAA / Privacy Authorization and Release of Information

The Patient acknowledges receipt of the Provider's Notice of Privacy Practices and authorizes the Provider to use and disclose protected health information for treatment, payment, and healthcare operations consistent with applicable law. The Patient authorizes release of medical records and billing information to insurance carriers, treating physicians, and other healthcare entities as necessary for payment and continuity of care.

Authorization to Obtain/Release Records: The Patient authorizes the release of prior dialysis records, hospital records, and other medical records to the Provider and authorizes the Provider to release records to third parties involved in the patient's care or payment.

Patient Responsibilities

The Patient agrees to follow the prescribed treatment plan, present for scheduled treatments or notify the facility in advance of cancellations, follow dietary and medication instructions, maintain access site care as instructed, report symptoms or complications promptly, and cooperate with necessary testing and follow-up appointments. Failure to comply may result in modification or termination of services in accordance with facility policy.

Consent Confirmations

By initialing and signing below, the Patient confirms: (a) understanding of the nature and purpose of the proposed dialysis treatment; (b) that risks, benefits and alternatives were explained; (c) voluntary consent to treatment; and (d) authorization of release of medical and billing information as described above.

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