Healthcare Electronic Consent Form

HEALTHCARE ELECTRONIC CONSENT FORM

Patient Information

Date of Birth:    Gender:

Primary Phone:    Email:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy Number:    Group Number:

Subscriber Date of Birth:

Medical History

Primary Care Physician:    Last Visit Date:

Consent for Electronic Communication and Treatment

I authorize the healthcare provider and its staff to communicate with me electronically regarding appointments, treatment instructions, billing, and health information via the methods I designate below. I understand that electronic communications may include unencrypted messages and that there are inherent risks in transmitting health information electronically.

Preferred electronic contact methods (check all that apply):
Email SMS/Text Phone Call Patient Portal

Email address for electronic communications:    Mobile phone for SMS/phone calls:

I consent to the use of electronic records and electronic signatures in connection with my care. I understand that consenting to electronic communications does not prevent me from requesting paper communications at any time.

Authorization to Treat and Procedure Details

I authorize the provider to perform the procedure(s) and to provide routine and emergency medical care related to the procedure. I acknowledge that reasonable alternatives, anticipated benefits, and material risks have been explained to me. I understand that results cannot be guaranteed and that complications may occur.

I further acknowledge my right to ask questions and to withdraw this consent at any time prior to treatment by notifying the provider, except where treatment has already been rendered in reliance on this consent.

Release of Information and HIPAA Acknowledgment

I authorize the release of my medical information to persons or entities involved in my care, payment, or healthcare operations as permitted by law. I acknowledge that a copy of the provider's privacy practices has been made available to me and that I understand my rights to access and request amendment of my health information.

I permit the provider to disclose my protected health information to the following individuals for purposes of care and billing (list names and relationship). If none, leave blank.

Revocation and Expiration

This authorization will remain in effect until revoked by me in writing, or until the expiration date below, whichever occurs first. I understand that revocation will not affect disclosures already made in reliance on this authorization.

Authorization Expiration Date:

Certifications and Patient Acknowledgment

By signing below I certify that I am the patient or I am legally authorized to consent on behalf of the patient. I have read and understand the information in this form, have had the opportunity to ask questions, and consent to the electronic communications, release of information, and treatment as indicated above. I understand that signing this form authorizes the use of electronic records and electronic signatures and that electronic communications may not be completely secure.

I understand that I may request a paper copy of this form and that I may revoke this authorization at any time by providing written notice to the provider, except to the extent that action has already been taken in reliance on this authorization.

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