Healthcare Executed PWC

HEALTHCARE EXECUTED PWC

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Other

Emergency Contact

Insurance Information

Medical History

Procedure / Service Consent

Description of Procedure/Service:

Proposed Date of Procedure:

Risks and Potential Complications: The patient acknowledges that no medical procedure is without risk. Significant risks may include, but are not limited to, infection, bleeding, adverse reaction to anesthesia, scarring, permanent impairment, or other complications specific to the procedure. The patient has been provided an opportunity to discuss the significant risks and understands them.

The patient understands they may withdraw consent at any time prior to initiation of the procedure without penalty to subsequent care. Withdrawal of consent will be documented in the medical record and discussed with the treating clinician.

By checking this box and signing below, I authorize the above-described procedure or care, acknowledge that the risks, benefits, and alternatives have been explained, and that my questions have been answered to my satisfaction.

HIPAA Authorization and Privacy Acknowledgment

I acknowledge receipt of the provider's Notice of Privacy Practices. I authorize the release of my protected health information as necessary for treatment, payment, and healthcare operations, including to my insurance carrier, referring physicians, and other providers involved in my care, as described below.

I acknowledge receipt of the Notice of Privacy Practices.

I authorize the release of my health information for purposes of treatment, payment, and healthcare operations and for the specific purposes indicated in this authorization.

Financial Responsibility

The undersigned accepts financial responsibility for charges not covered by insurance, including deductibles, copayments, coinsurance, and non-covered services. Assignment of benefits to the provider is granted where required. The facility and clinicians may bill my insurance and I authorize payment of benefits directly to the provider.

I accept financial responsibility as stated above.

Representations and Certifications

I certify that the information I have provided on this form is true and complete to the best of my knowledge. I understand that intentional misrepresentation may affect my care and insurance coverage. I consent to treatment and to the uses and disclosures described in this document.

If signing on behalf of the patient, I certify that I am the legal guardian, parent, or authorized representative and have authority to execute this consent on the patient’s behalf.

Additional Instructions / Patient Notes

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