Healthcare FOC and ROI Form

Healthcare FOC and ROI Form

Patient Information

Insurance Information

Medical History (for treatment planning)

Form of Consent (FOC) — Consent to Treatment

I, the undersigned patient or legal representative, hereby consent to the provision of health care services described below. I authorize qualified personnel to perform the procedures and provide care indicated. I have had the nature, anticipated benefits, material risks, and reasonable alternatives explained to me and have had the opportunity to ask questions.

By checking the boxes below I acknowledge that the explanations described above were provided and understood:

I understand the significant risks and complications that may reasonably be associated with the proposed treatment.

I understand the expected benefits and likely outcome if the proposed treatment is successful.

I have been informed of reasonable alternatives, including the option of no treatment, and their material risks and benefits.

I understand I may withdraw this consent at any time orally or in writing, except to the extent that action has already been taken in reliance on this consent.

I confirm that this consent is given voluntarily and without coercion; refusal of treatment will not result in denial of other appropriate care.

Release of Information (ROI) — Authorization to Disclose Protected Health Information

I authorize the disclosure of my protected health information as specified below. This authorization is voluntary and will be used only for the purpose(s) specified and to the recipient(s) named below unless otherwise revoked by me in writing. Information disclosed pursuant to this authorization may include records created by different providers and may include sensitive categories as indicated.

Records to be disclosed (check all that apply):

Entire medical record

Limited records — specify:

Inclusion of sensitive information (explicit authorization required — check only if you authorize disclosure):

HIV/AIDS related information

Substance use disorder treatment records

Mental health / psychotherapy notes

I understand that I may revoke this authorization at any time by submitting a signed, written notice of revocation to the health care provider or health information custodian identified on this form. Revocation will not affect disclosures already made in reliance on this authorization prior to receipt of the revocation.

I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by the original custodian. Federal and state law may further protect certain categories of information; this authorization does not supersede those protections unless expressly stated.

I acknowledge that I may be charged reasonable fees for copying and mailing records in accordance with applicable law. I understand that payment of fees does not obligate the provider to fulfill requests that are not permitted by law.

I acknowledge receipt of the Notice of Privacy Practices and understand my rights with respect to my protected health information, including the right to inspect and copy information disclosed under this authorization where applicable.

Certification

By signing below I certify that I am the patient or the patient’s legally authorized representative and that the information provided on this form is true and correct to the best of my knowledge. My signature confirms that I have read and understand the contents of this form and authorize the actions described herein.

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