Healthcare Ellipsis Agreement

HEALTHCARE ELLIPSIS AGREEMENT

Patient Name:     Date of Birth:     Gender:

Address:

Primary Phone:     Email:

Emergency Contact

Insurance Information

Medical History

Scope of Care and Procedure Description

Provider shall render the healthcare services described below and as reasonably necessary in the professional judgment of Provider to address the patient’s presenting condition. Description of proposed care, procedure, or treatment plan:

Risks, Benefits, and Alternatives

I acknowledge that Provider has explained the nature, purpose, reasonably foreseeable benefits, material risks, and reasonable alternatives (including the option of no treatment) related to the proposed care described above. No warranty or guarantee has been made regarding the results of the treatment. Material risks may include, but are not limited to, infection, bleeding, allergic reaction, adverse drug interaction, exacerbation of existing conditions, or the need for further procedures.

I understand that I may ask questions at any time and that I may withdraw consent to the proposed care at any time prior to or during treatment, subject to any applicable emergency treatment or scope of professional care obligations.

I acknowledge that risks, benefits, and alternatives have been explained to me and I have had the opportunity to ask questions.

HIPAA Authorization and Release of Information

I hereby authorize Provider to use and disclose my protected health information (PHI) as reasonably necessary for treatment, payment, and healthcare operations and for the specific purposes identified below. This authorization specifically includes disclosure of diagnosis, treatment records, imaging, laboratory results, and billing information as needed to coordinate care and process claims.

I understand that I may revoke this authorization at any time by delivering written notice to Provider, except to the extent that Provider has already acted in reliance on this authorization. I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations.

Financial Responsibility and Assignment

I accept financial responsibility for services provided and agree to pay applicable co-payments, co-insurance, deductibles, and amounts not covered by insurance. I authorize Provider to bill my insurance and to release any information necessary to process claims. I assign to Provider any benefits payable for services rendered.

I authorize payment of insurance benefits directly to Provider where applicable.

Voluntary Consent and Certification

By signing below I certify that I am the patient or legally authorized representative of the patient, that I have read and understand this Healthcare Ellipsis Agreement in its entirety, that all information provided is true and accurate to the best of my knowledge, and that I consent voluntarily to the treatment and authorizations described above.

Acknowledgment of Privacy Practices

I acknowledge that I have been offered or provided with a copy of Provider’s Notice of Privacy Practices describing how my health information may be used and disclosed and how I can access this information. I understand my rights and how to exercise them under applicable law.

I acknowledge receipt of the Notice of Privacy Practices (or that it was offered).

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