Healthcare EESA Combo

HEALTHCARE EESA COMBO

Patient Identification

Patient Name:     Date of Birth:

Emergency Contact

Insurance Information

Medical History

Emergency Evaluation & Stabilization Authorization (EESA)

I, , hereby authorize clinicians to perform emergency evaluation and stabilization services as indicated below. This authorization includes administration of medications, diagnostic testing, intravenous access, imaging, wound care, and other interventions necessary to evaluate and stabilize acute medical or psychiatric conditions.

Procedure / Service Description:

Risks: The risks of emergency evaluation and stabilization procedures may include, but are not limited to, allergic reaction to medications, bleeding at puncture sites, infection, adverse medication effects, incomplete resolution of the emergency condition, and other risks associated with diagnostic procedures. Benefits: prompt diagnosis, control of acute symptoms, prevention of deterioration, and facilitation of definitive care. Alternatives: decline treatment, outpatient follow-up, or transfer to another facility when safe and feasible.

By signing this form I acknowledge that the risks, benefits, and alternatives have been explained to me to the extent reasonably possible in an emergency context, that reasonable attempts were made to discuss these matters with me, and that immediate treatment is necessary. I understand that I may withdraw consent at any time unless withdrawal would jeopardize my safety or the provision of necessary emergency care.

Specific Authorizations and Preferences

Please indicate consent where applicable:

  I consent to administration of emergency medications as indicated.

  I consent to blood draw and transfusion if medically necessary.

  I consent to radiographic imaging and other diagnostic studies.

  I consent to transfer to another facility for higher level of care if required.

HIPAA Authorization and Release of Information

I authorize the use and disclosure of my protected health information to facilitate my care, billing, and coordination of services. I specifically authorize disclosure to the emergency contact(s) named in this form and to my insurer for the purpose of claims and payment.

I specifically authorize release of the following categories of information (check all that apply):

  General medical records      Mental health records      Substance use treatment records      HIV-related information

I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance upon it. Revocation must be submitted in writing to the facility Health Information Management department or the attending clinician and will not affect disclosures made prior to receipt of the revocation.

Financial Responsibility & Miscellaneous

I agree to be financially responsible for services not paid by my insurance, including co-payments, deductibles, and non-covered services. This authorization for treatment is independent of insurance coverage determinations.

Interpreter services provided:     Patient capacity:

If patient lacks capacity or is a minor, indicate legal representative:

Acknowledgments

  I acknowledge receipt of the facility's Notice of Privacy Practices or that a good-faith attempt was made to provide such notice in the emergency setting.

  I understand my right to withdraw consent when clinically appropriate and that emergency treatment may continue if withdrawal would place my health at risk.

I certify under penalty of law that the information I have provided on this form is true and accurate to the best of my knowledge, and that I have the authority to execute this authorization if signing on behalf of the patient.

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