Healthcare Election Form

HEALTHCARE ELECTION FORM

This Healthcare Election Form documents the patient’s affirmative elections and declines regarding clinical care, release of health information, assignment of benefits, communication preferences, research participation, organ/tissue donation, and related authorizations. By signing this form the patient certifies that the selections made below reflect their informed choices and that they understand the rights to revoke or modify these elections as described in the acknowledgments and HIPAA privacy notice set forth in this document.

Patient Information

Insurance Information

Medical History (relevant)

Elections, Authorizations, and Consents

1. Consent for Routine and Emergency Treatment — I authorize healthcare personnel to provide routine diagnostic and therapeutic services deemed necessary for my care, including emergency interventions when delay would jeopardize health. I understand that separate written consent may be required for specific invasive procedures.

I elect: Consent Decline

2. Anesthesia and Sedation — I authorize administration of local, regional, or general anesthesia or sedation as necessary for the indicated procedure(s). I understand there are risks associated with anesthesia including, but not limited to, allergic reaction, respiratory compromise, and, rarely, death.

I elect: Consent Decline

3. Diagnostic Testing — I consent to necessary diagnostic tests (laboratory, imaging, pathology) in connection with my care. Test results may be used for clinical decision-making and, where permitted, quality assurance and safety review.

I elect: Consent Decline

4. Release of Medical Information — I authorize disclosure of my protected health information to the following person(s) or entity(ies) for purposes of treatment, payment, and healthcare operations as permitted by law. This authorization does not limit disclosures otherwise required or permitted by law.

Authorize release to named person(s) Do not authorize release

5. Assignment of Benefits and Financial Responsibility — I authorize payment of medical benefits to the treating provider when applicable. I remain financially responsible for charges not covered by insurance, including deductibles, co-payments, co-insurance, or non-covered services. I understand that assignment of benefits does not guarantee payment by my insurer.

Assign benefits to provider Do not assign

6. Communications and Privacy Preferences — I authorize the use of voicemail, text messaging, and/or email to communicate appointment reminders, treatment information, and billing statements to the contact information provided above. I understand that communications may not be encrypted and that there is some risk of interception.

Allow voicemail messages Allow text messages Allow email Decline all electronic communications

7. Research, Photography, and Recordings — I understand that participation in research, photography, audio or video recording for educational or publication purposes requires explicit consent. Standard clinical care images or recordings may be made for clinical documentation. Separate written consent will be sought for research or publication use.

Consent to research participation Decline research participation

Consent to photography for clinical documentation Decline photography/recording

8. Organ and Tissue Donation — I indicate my preference regarding organ and tissue donation. This election will be used to inform hospital processes but does not modify any state registry status or other legal documents unless explicitly stated below.

I elect to donate organs/tissues for transplantation or research I decline organ/tissue donation

9. Advance Directive / Durable Power of Attorney for Healthcare — Please indicate whether you have an advance directive or healthcare power of attorney on file with this provider. If you have provided a copy, indicate where it is kept.

Advance directive / power of attorney is on file No advance directive on file

HIPAA Privacy Acknowledgment and Certification

I acknowledge receipt of the provider’s privacy practices and understand my rights under federal and state law to access and control my protected health information. I authorize disclosures and uses consistent with my selections above. 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 on it.

I acknowledge receipt of the privacy notice and understand my rights

Certification

I certify that the information provided on this form is true and accurate to the best of my knowledge. I understand that my elections will be followed as stated unless they are inconsistent with urgent clinical needs or applicable law. I understand my right to modify or revoke any election in writing, and that such modification will not affect actions taken in reliance on my prior election.

Sign Now