Healthcare Dialysis Authorization Form

HEALTHCARE DIALYSIS AUTHORIZATION FORM

Patient Name:   Medical Record #:

Patient Information

Date of Birth:   Gender:

Phone:   Alternate Phone:

Insurance and Billing Information

Policy/ID #:   Group #:

Medical History / Current Status

Dialysis Treatment Authorization

Ordering Physician:

Physician Phone:   Order Date:

Hemodialysis    Peritoneal Dialysis    Other:

Fistula    Graft    Central Venous Catheter    Other:

Frequency:   Duration per session:   Treatment Start Date:

I hereby authorize the dialysis facility and its licensed practitioners to provide and carry out the ordered dialysis treatment and related procedures, including but not limited to vascular access care, administration of dialysis-related medications, intravenous fluids, blood products when medically indicated, laboratory testing, and emergency interventions as necessary to preserve life and prevent significant harm. This authorization includes minor and routine procedures associated with dialysis care.

I consent to receive blood products if clinically indicated.    I do not consent to receive blood products.   If refused, discuss alternative measures with treating team.

Risks, Benefits, Alternatives

Risks: I understand that dialysis carries risks, including but not limited to infection at access site, bleeding, hypotension, cramping, electrolyte disturbances, vascular access failure, air embolism, allergic reactions to dialyzer components or medications, need for emergent hospitalization, and in rare cases permanent disability or death. The facility has explained common and serious risks, and I have had the opportunity to ask questions.

Benefits: I understand the anticipated benefits of dialysis may include removal of excess fluid and waste products, improved symptoms, and life-sustaining support. Alternatives: Alternatives to the proposed treatment (including conservative management, medical therapy, or different modalities of renal replacement therapy) have been explained to me as appropriate to my condition.

Right to Refuse or Withdraw: I understand that I may refuse or withdraw consent to dialysis at any time, except as limited by law or where immediate treatment is required to prevent serious harm. If I withdraw consent, the treating clinicians will discuss alternative care plans and document my decision.

Authorization to Use and Disclose Health Information (HIPAA)

I authorize the dialysis facility and its practitioners to use and disclose my protected health information (PHI) for purposes of treatment, payment, and healthcare operations related to my dialysis care. This includes sharing information with physicians, hospitals, laboratory services, payors, and other entities directly involved in my care or billing for services.

Expiration of Authorization: Unless earlier revoked, this authorization will expire on: . I understand I may revoke this authorization in writing at any time, except to the extent that the facility has already acted in reliance on this authorization.

Redisclosure: I understand that information disclosed pursuant to this authorization may be redisclosed by the recipient and may no longer be protected by privacy regulations. The facility will make reasonable efforts to limit disclosures to the minimum necessary to accomplish the stated purpose.

Advance Directives / Special Wishes

Do you have an advance directive, living will, or durable power of attorney for healthcare?    Yes    No

Acknowledgment and Certification

By signing below, I certify that I have read (or have had read to me) and understand the information contained in this Dialysis Authorization Form. I have had the opportunity to ask questions about the nature, risks, benefits, and alternatives to the proposed dialysis treatment and those questions have been answered to my satisfaction. I authorize the dialysis facility and its staff to perform the treatment and related procedures described above.

I acknowledge financial responsibility for services rendered and understand that my insurance may not cover all charges. I authorize release of medical information necessary for treatment, payment, and healthcare operations as described above.

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