Healthcare ICF Approval Form

HEALTHCARE ICF APPROVAL FORM

Patient Name:    Medical Record / ID:

Patient Information

Month:    Day:    Year:

Insurance Information

Medical History

None reported

Procedure / Intervention

Proposed Procedure Date: Month    Day    Year

Risks, Benefits and Alternatives

The clinician has explained the nature and purpose of the proposed procedure, material risks (including common and significant but rare complications), potential benefits, and reasonable alternatives including no treatment. I acknowledge that I have had the opportunity to ask questions and receive answers in language I understand.

I acknowledge the following (initial or check each):

Risks and potential complications were explained to me.    Expected benefits were explained to me.

Reasonable alternatives, including non-treatment, were discussed.

Voluntary Consent and Right to Withdraw

I understand that my consent to the procedure is voluntary and that I may withdraw consent at any time before the procedure without affecting my right to future care or treatment by the facility. If I withdraw consent after sedation or placement of devices, additional risks may result; these were explained to me.

I understand my right to withdraw consent and acknowledge the above.

HIPAA / Privacy Authorization

I acknowledge that I have received the facility's privacy notice and that my protected health information may be used and disclosed for treatment, payment, and healthcare operations in accordance with that notice. I authorize disclosure of relevant health information to third parties as necessary for the provision of care and billing.

I acknowledge receipt of the privacy notice and authorize use/disclosure as described above.

Authorization Duration

This authorization for treatment and release of information expires on: Month    Day    Year

Patient Certification

I certify that I have read (or have had read to me) the information on this form, that the explanations offered to me regarding the procedure, risks, benefits and alternatives were satisfactory, and that all my questions have been answered. I authorize the health care providers and facility staff to perform the procedure described above and to provide such care as is necessary in connection therewith.

I understand that the practice of medicine and surgery is not an exact science and that no guarantees have been made to me concerning the results of the procedure.

If signing on behalf of the patient, the signer certifies that they are the legal representative or guardian and have authority to sign on the patient's behalf. Relationship to patient:

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