Healthcare Emergency Services Agreement

Healthcare Emergency Services Agreement

Patient Information

Patient Name:

Emergency Contact

Provider / Facility Information

Insurance / Billing Information

Medical History (Brief)

Agreement to Emergency Services

I, the undersigned patient or legal representative, authorize the Provider and agents to assess, stabilize, diagnose, treat and arrange transport as reasonably necessary in the exercise of professional judgment for emergency medical conditions. I understand that the nature of emergency care may require interventions including but not limited to medication administration, imaging studies, invasive procedures and transfer to another facility.

Date of Encounter (if applicable):

Nature of Emergency / Brief Description of Services to be Provided:

Financial Responsibility and Assignment

Patient agrees to be financially responsible for charges not covered by insurance, including applicable co-payments, deductibles and non-covered services. Patient hereby assigns to the Provider all rights to insurance proceeds and benefits for services rendered, and authorizes payment of those benefits directly to the Provider to the extent permitted by the insurer.

Estimated payment responsibility (if provided): $

If I am unable to promptly provide insurance information, I agree that the Provider may bill me directly and I will remain responsible for all unpaid balances.

Risks, Benefits and Alternatives

The benefits of prompt emergency treatment include stabilizing life-threatening conditions and preventing further harm. Risks may include adverse reactions to medications, procedural complications, infection or unexpected outcomes. Alternatives may include observation, outpatient treatment or transfer to another facility; however, in emergency circumstances such alternatives may not be reasonable or safe. I acknowledge that no guarantee of outcome is given.

HIPAA / Privacy Acknowledgment

I acknowledge that I have been offered or provided a copy of the Provider's Notice of Privacy Practices describing how my medical information may be used and disclosed. I authorize the Provider to use and disclose my protected health information for treatment, payment and health care operations, and for communication with family members or emergency contacts as necessary for my care.

Authorization Duration and Revocation

This authorization is effective immediately and shall remain in effect until the earlier of the completion of the emergency episode or until revoked in writing. To revoke, deliver a written notice to the Provider; revocation will not affect actions already taken in reliance on this authorization.

Certification

By signing below I certify that the information I have provided on this form is true and accurate to the best of my knowledge. I authorize the Provider to perform emergency medical services as necessary. I accept financial responsibility as stated above and authorize release of information as required for treatment and payment.

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