Healthcare ER Paperwork Form

HEALTHCARE ER PAPERWORK FORM

Patient Information

Date of Birth:    Gender: Male Female Other

Insurance Information

Subscriber Date of Birth:

Medical History

Chronic Conditions (check all that apply):
Diabetes   Hypertension   Heart Disease   Asthma / COPD   Other:

Are you pregnant or could be pregnant? Yes No

Last oral intake (time / substance):

Consent for Emergency Treatment

I hereby authorize physicians, nursing staff and other designated clinical personnel of the emergency department to provide necessary emergency medical care, diagnostic testing, medications, procedures and stabilization as clinically indicated. This consent includes, but is not limited to: intravenous fluids, wound treatment, suturing, splinting, sedation when necessary for procedures, imaging studies and laboratory testing.

Risks and potential complications may include infection, bleeding, allergic or adverse reactions, pain, scarring, need for additional procedures, and unforeseen complications consistent with emergency care. Benefits include diagnosis, symptom relief, stabilization of medical condition and prevention of further harm. The treating clinician has explained the reason for care and alternatives when time permits.

I understand that I have the right to ask questions, to refuse treatment, or to withdraw consent to the extent permitted by applicable law and clinical circumstance. I understand that in an emergency situation, life-saving treatment may be provided even if I am unable to provide informed consent.

HIPAA Privacy & Release Authorization

I acknowledge that the facility’s Notice of Privacy Practices has been made available to me and that I understand my rights regarding the privacy of my protected health information. I authorize the facility to disclose relevant portions of my medical record to the persons named below for continuity of care, billing or notification purposes.

This authorization is voluntary. 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 understand that this authorization will expire on: . If no date is provided, this authorization will expire one year from the date of signature unless otherwise limited by law.

Financial Responsibility & Billing

I assign benefits to the facility and authorize payment of insurance benefits directly to the facility for services rendered. I accept financial responsibility for charges not covered by insurance, including co-payments, deductibles, and amounts determined to be patient responsibility under my plan. I certify the information provided on this form is true and complete to the best of my knowledge.

Additional Clinical & Administrative Information

Do you have an advance directive (living will / durable power of attorney for healthcare)? Yes No

Language / Interpreter needed:

Patient Certification and Signature

By signing below, I certify that I have read and understand the information on this form (or it has been explained to me). I consent to the emergency treatment described above, authorize release of health information as specified, accept financial responsibility as stated, and declare that the information I have provided is accurate and complete. If signing as a legal guardian or representative, I certify that I am authorized to sign on behalf of the patient and will provide documentation upon request.

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