Healthcare Final Draft Form

Healthcare Final Draft Form

Patient Information

Patient Name:

Female Male Other Prefer not to say

Emergency Contact

Insurance Information

Medical History

Consent for Treatment

By signing this form I, the undersigned patient or legal representative, hereby consent to the provision of medical care, diagnostic tests, medical procedures and related services deemed necessary by the healthcare providers. I acknowledge that the nature of proposed treatment, anticipated benefits, material risks, potential complications, and reasonably available alternative treatments have been explained to me in language I understand. I understand that no guarantee has been made as to the results of the treatment.

I understand that I have the right to refuse any treatment or withdraw consent at any time, except to the extent that withdrawal of consent may result in immediate harm to myself or others or is otherwise restricted by law. I authorize clinicians to obtain necessary consultations, administer medications, perform procedures, and to order diagnostic testing as may be required for my care.

Authorization to Release Medical Records

I authorize the release of my protected health information to the persons or entities identified below for purposes of treatment, payment, or healthcare operations as described. This authorization includes, but is not limited to, clinic notes, laboratory results, imaging reports, and discharge summaries unless specifically excluded herein.

This authorization is valid until: unless earlier revoked in writing. I understand that revocation does not apply to information already released in reliance on this authorization.

HIPAA Privacy Acknowledgment

I acknowledge receipt of the practice's Notice of Privacy Practices and understand how my health information may be used and disclosed. I understand my rights concerning my protected health information and that I may request restrictions or an accounting of disclosures as provided by law.

I acknowledge that I have received and reviewed the privacy practices notice.

Additional Clinical Information / Instructions

Acknowledgments and Certifications

I certify that the information I have provided on this form is true and correct to the best of my knowledge. I understand that intentional falsification of information may affect my care and may be subject to penalties under applicable law. I authorize the release of information necessary to process insurance claims and assign payment of benefits to the provider, unless otherwise stated in writing.

I understand that I may be financially responsible for services not covered by insurance or for which coverage is denied. I have been given the opportunity to ask questions about the proposed care, and those questions have been answered to my satisfaction.

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