Healthcare Informed Consent Agreement

HEALTHCARE INFORMED CONSENT AGREEMENT

Patient Information

Patient Name:

Date of Birth:    Gender:    Phone:

Insurance Information

Policy / ID Number:    Group Number:

Medical History

Are you pregnant or suspect pregnancy?   Yes   No

Procedure / Treatment Description

Purpose and Expected Benefit: I understand that the purpose of the above procedure/treatment is to treat or diagnose the condition described and that expected benefits include improvement of my condition though no guarantee has been made. I acknowledge that alternative treatments, including no treatment, have been explained to me.

Risks, Complications and Acknowledgments

I understand that risks and complications may include, but are not limited to: infection, bleeding, delayed healing, scarring, anesthesia-related complications (including respiratory or cardiac events), allergic reaction to medications or materials, nerve injury, need for additional procedures, or death. Specific risks related to this procedure include:

By initialing and checking the boxes below I indicate that these points were discussed with me and I understand them:

I understand the risks and potential complications described above.

Alternatives, including the option of no treatment, were explained to me.

I have had the opportunity to ask questions and all my questions have been answered to my satisfaction.

Consent for Related Procedures and Authorizations

I authorize the attending provider and such assistants as may be necessary to perform the procedure and to provide such additional medical care as may be necessary in the event of unexpected findings or complications. I consent to administration of local, regional or general anesthesia as deemed appropriate by my provider.

I consent to the administration of anesthesia when required.

I consent to blood transfusion and blood products if medically necessary.

I consent to clinical photography/video for medical documentation, education, or treatment planning (images may be used internally without identifying information).

Authorization for Use and Disclosure of Medical Information

I authorize the use and disclosure of my protected health information to the extent necessary for treatment, payment, and health care operations. I authorize release of information to insurance carriers, third-party payors, and entities involved in my care for the purpose of billing and claims processing.

I authorize release of necessary medical and billing information to my insurer or its agents for claims processing.

HIPAA / Privacy Acknowledgment

I acknowledge that I have been offered a copy of the Notice of Privacy Practices describing how my medical information may be used and disclosed and how I can access this information. I understand my rights regarding my protected health information.

I acknowledge receipt of the Notice of Privacy Practices.

Patient Certification and Signature

I certify that I have read (or have had read to me) the foregoing information, that the nature, purpose, benefits and risks of the proposed procedure and alternatives have been explained to me, and that I have had an opportunity to ask questions. I understand that I may withdraw my consent at any time prior to the procedure by notifying the attending provider, except where action has already been taken in reliance upon this consent.

I hereby authorize the provider named above to perform the procedure and related care as described. I accept financial responsibility for charges not covered by insurance and authorize assignment of benefits to the provider as necessary for payment.

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