Healthcare EKG Labs Form

HEALTHCARE EKG LABS FORM

Patient Information

Patient Name:    Date of Birth:

Gender: Male Female Other/Prefer not to say

Insurance Information

Clinical Indication & Procedure Details

Reason for EKG (clinical indication):

Procedure Date:    Procedure Time:    Type: Resting Stress Telemetry

Medical History

Has a pacemaker or implantable cardioverter-defibrillator (ICD)? Yes No

Prior cardiac history (check all that apply): Hypertension Diabetes Prior myocardial infarction Arrhythmia

Risks, Benefits, Alternatives & Consent

I, the undersigned, authorize the performance of the electrocardiogram (EKG/ECG) described above. The nature of the procedure, anticipated benefits, and possible risks have been explained. Risks are minimal and may include mild skin irritation from electrodes or discomfort while remaining still; rare complications have been explained when applicable. I understand that the EKG is a diagnostic tool and that results will be interpreted by qualified personnel.

I understand that alternative diagnostic approaches may be available and have had the opportunity to ask questions. I have the right to refuse or withdraw consent at any time before the procedure without affecting my future care.

Authorization to release test results: Release to ordering physician Release to other (complete below)

Privacy and HIPAA Acknowledgment

I acknowledge that I have received the facility's Notice of Privacy Practices describing how my protected health information may be used and disclosed. I authorize the use and disclosure of my health information as necessary to provide care, process claims, and communicate results to designated providers or other parties I have authorized. I understand I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance on it.

Patient acknowledges and consents to the secure retention of EKG data and to the transmission of results to the ordering provider and to the electronic health record as required for continuity of care.

Acknowledgment: I acknowledge and agree

Ordering Provider / Clinical Information

Patient Declaration and Consent

By signing below I certify that I am the patient or legal representative authorized to consent for the patient. I have read (or have had read to me) the information on this form and understand the purpose, benefits, and risks of the EKG. I authorize the performance of the EKG and any routine procedures incident to it. I authorize the release of results as indicated above.

Sign Now