Healthcare Excise Treatment Form

HEALTHCARE EXCISE TREATMENT FORM

Patient Information

Date of Birth:    Gender:    Medical Record #:

Home Phone:    Cell Phone:

Relationship:    Phone:

Insurance Information

Policy/ID #:    Group #:

Relevant Medical History

Procedure Description and Clinical Indication

Intended Procedure:    Anatomic Site:

Clinical Indication / Diagnosis:

Proposed Anesthesia:    Estimated Duration:

Risks, Benefits, and Alternatives

I acknowledge that the clinician has explained the nature and purpose of the excisional treatment, expected benefits, and reasonable alternatives, including no treatment. I understand that no outcome can be guaranteed. Common and material risks include, but are not limited to: bleeding, infection, scarring, nerve injury, incomplete excision requiring further treatment, adverse reaction to anesthesia, and rare unanticipated complications. I have had the opportunity to ask questions and have them answered to my satisfaction.

I acknowledge that the risks, benefits, and alternatives have been explained to me and that I understand them.

Specimen Handling and Pathology

Excised tissue will be submitted for pathological examination as clinically indicated. I authorize the health care facility and physician to retain, process and examine specimens for diagnostic purposes.

I consent to submission of excised tissue for diagnostic pathology.

Disposal of Residual Tissue: I authorize routine disposal of residual tissue after diagnostic evaluation / Retain for research only with separate consent.

HIPAA / Privacy Acknowledgment

I have received and/or been offered the facility's Notice of Privacy Practices describing how my protected health information may be used and disclosed, and my rights with respect to that information under applicable law.

I acknowledge receipt of the privacy notice or that the notice was offered to me.

Patient Rights and Withdrawal

I understand that I may withdraw my consent at any time prior to the start of the procedure by notifying the clinician or staff. Withdrawal of consent will not affect the continuity of care or billing for services already rendered.

I understand my right to withdraw consent prior to the procedure.

Authorization Duration and Additional Consents

This authorization to perform the described excisional treatment shall remain in effect until the procedure is completed or until revoked in writing prior to the procedure. Authorization expiration date (if different from procedure date):

Photography/Documentation: I consent to medical photography/video for documentation and clinical use only (not for teaching/research unless separate consent is obtained).

Certification and Authorization

By signing below I certify that I have read (or have had read to me) this form, that the procedure, risks, benefits and alternatives have been explained, that my questions have been answered, and that I hereby authorize the physician and clinical staff to perform the excisional treatment described above. I authorize the performance of such additional procedures as are necessary or advisable in the clinician's professional judgment for my safety and well-being. I understand there are no guarantees regarding outcome and that complications may occur.

I authorize the release of medical information necessary for payment of health care benefits and understand I am financially responsible for any charges not covered by insurance.

Patient Initials:

If signed by a legal guardian, parent, or authorized representative, complete the following:

Representative Name (if applicable)

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