Healthcare Gastro Agreement

HEALTHCARE GASTRO AGREEMENT

This Healthcare Gastroenterology Services Agreement (Agreement) is entered into between Provider Name: and Patient Name: . Agreement Effective Date:

Patient Information

Emergency Contact

Insurance Information

Medical History

Procedure Consent and Agreement

Procedure to be performed (describe):

I consent to the performance of the procedure described above, including any diagnostic or therapeutic interventions deemed necessary by the Provider, such as biopsy, polypectomy, dilation, or hemostasis. I understand that no guarantee of cure or specific result is made.

The Provider may administer sedation or anesthesia as required. Select applicable options:
Moderate (conscious) sedation Deep sedation General anesthesia Local/topical anesthesia

Risks, Benefits and Alternatives

The Patient acknowledges that the Provider has explained the nature, purpose, anticipated benefits, and material risks of the procedure. Material risks include, without limitation: bleeding, infection, perforation of the gastrointestinal tract, adverse reaction to sedation or medications, cardiopulmonary complications, need for transfusion, need for additional procedures or surgery, missed lesions, and death. The risk profile varies with patient comorbidities and the specific procedure.

Alternatives to the proposed procedure, including non-procedural management, imaging studies, and alternative interventions, have been discussed. The Patient has had the opportunity to ask questions and all questions have been answered to the Patient's satisfaction.

Acknowledgment: I acknowledge that I understand the risks, benefits, and alternatives described above and consent to the procedure.

Specimens, Photographs and Pathology

I authorize collection of tissue or specimens and submission for histopathologic and laboratory examination. I authorize the Provider to take photographs or video for medical documentation. I understand that pathology and laboratory results will be used for diagnosis and treatment and will become part of my medical record.

Consent for biopsy/specimen handling: Yes No

Financial Responsibility and Assignment

The Patient agrees to be financially responsible for all charges not covered by insurance or other third-party payers, including deductibles, co-payments, co-insurance, and amounts denied as not medically necessary. The Patient hereby assigns to the Provider any rights to benefits for services rendered and authorizes payment directly to the Provider where applicable.

I agree to financial responsibility and assignment of benefits as described above.

HIPAA Authorization and Release of Information

I acknowledge receipt of the Provider's Notice of Privacy Practices and authorize the Provider to use and disclose my protected health information for treatment, payment, and healthcare operations, including release to insurance carriers, referring physicians, and laboratories as required. This authorization includes release of records related to the procedure, pathology, and billing.

I acknowledge and authorize the use and disclosure described above.

Revocation and Withdrawal

The Patient may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on this authorization. Revocation does not affect disclosures already made in reliance on the authorization prior to receipt of revocation by the Provider. The Patient has the right to refuse or withdraw consent; however, withdrawal may not be possible once a procedure has commenced.

Certification

I certify that the information I have provided on this form is true and accurate to the best of my knowledge. I understand the nature of the proposed procedure(s), the reasonably foreseeable risks and complications, and the alternatives. I have had the opportunity to ask questions and have received satisfactory answers.

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