Healthcare ICF Form

Healthcare ICF Form

Patient Information

Male Female Other Prefer not to say

Insurance Information

Medical History

Chronic Conditions (check all that apply)

Diabetes Hypertension Heart disease Asthma / COPD None of the above

Procedure / Treatment Information

Scheduled Date:

Risks, Benefits, and Alternatives

I acknowledge that the performing clinician has explained the nature and purpose of the proposed procedure or treatment, the anticipated benefits, and the reasonably foreseeable risks including, but not limited to: infection, bleeding, scarring, adverse reaction to medication or anesthesia, failure to achieve the intended benefit, and unanticipated complications that may require additional treatment. Rare but serious risks may occur and have been described to me when applicable.

Alternatives to the proposed procedure including no treatment, medical management, or alternative procedures were explained to me, and I have had an opportunity to ask questions and to refuse the procedure. I understand that results cannot be guaranteed.

Patient acknowledges: I have read and understand the risks and benefits described above.

Voluntary Consent and Withdrawal

I voluntarily consent to the proposed procedure or treatment. I understand that I may withdraw this consent at any time prior to the procedure without affecting my right to future care or treatment. Withdrawal of consent should be made in writing when feasible, but may be made orally in urgent situations.

Patient acknowledges: I understand I may withdraw consent at any time.

HIPAA / Privacy and Authorization

I acknowledge that I have been provided with information about privacy practices and how my protected health information may be used and disclosed for treatment, payment, and health care operations. I authorize the disclosure of my protected health information as is reasonably necessary for purposes related to this procedure including referrals, billing, and coordination of care.

This authorization expires on:

Patient acknowledges: I authorize the release of health information as described above.

Certification and Signatures

By signing below I certify that I have read (or had read to me) the information on this form, that the procedure and alternatives were explained to my satisfaction, that my questions have been answered, and that I understand the nature and consequences of the proposed treatment. I certify that the information I have provided on this form is complete and accurate to the best of my knowledge.

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