Healthcare LHC Form

Healthcare LHC Form

Patient Information

Date of Birth:   Gender: Male Female Other

Insurance Information

Medical History

Please indicate chronic conditions (check all that apply): Hypertension Diabetes COPD / Respiratory disease Kidney disease

Procedure: Left Heart Catheterization (LHC) — Consent

I authorize and consent to the performance of Left Heart Catheterization (LHC), cardiac catheterization, coronary angiography, and related diagnostic and therapeutic procedures as indicated by the treating physician. These procedures may include coronary angioplasty, stent placement, intravascular imaging, hemodynamic measurements, and administration of contrast agents or medications required during the procedure.

Purpose: The LHC is intended to evaluate coronary anatomy and cardiac function and to provide therapeutic interventions if clinically indicated. The anticipated benefits are diagnostic information and the potential to restore or improve coronary blood flow.

Risks: I understand that the procedure involves risks that include, but are not limited to: bleeding at the access site; hematoma; infection; arterial damage; formation of a pseudoaneurysm; arrhythmia; stroke; heart attack; contrast-induced kidney injury; allergic reaction to contrast or medications; need for emergency surgery including coronary artery bypass graft; blood transfusion; permanent disability; and death. Less common risks specific to this procedure may include vascular thrombosis, limb ischemia, and nerve injury.

Alternatives: Alternative treatments and diagnostic options have been explained, including medical management, noninvasive testing, and postponement of the procedure. I have had the opportunity to ask questions about alternatives and to discuss potential outcomes with my provider.

Anesthesia and Sedation: Sedation, local anesthesia at the vascular access site, and/or general anesthesia may be used as appropriate. I consent to the administration of sedatives, analgesics, and related medications as needed during the procedure. I understand these medications carry their own risks.

Blood Products: I consent to the administration of blood products and blood derivatives during or after the procedure if deemed medically necessary in an emergency.

Right to Withdraw: I understand that I may withdraw this consent at any time prior to the procedure; however, withdrawal will not affect actions already taken based on this consent and may not be feasible in urgent or emergency circumstances.

I acknowledge that the treating physician has explained the nature of the procedure, the expected benefits, the material risks, foreseeable complications, and reasonable alternatives. I have had the chance to ask questions and all questions have been answered to my satisfaction.

HIPAA Authorization & Release of Information

I authorize the disclosure of my protected health information to other healthcare providers, insurers, and authorized representatives for treatment, payment, and healthcare operations related to this procedure. I authorize release of medical records, images, and procedure notes as reasonably necessary for coordination of care and insurance claims.

I authorize the facility and the treating providers to communicate information concerning my condition and treatment to the following persons (name and relationship). If none, leave blank.

Authorization Expiration Date:   If no date provided, this authorization expires one year from the date of signature below.

Financial Responsibility & Assignment

I accept financial responsibility for charges not covered by insurance. I authorize assignment of insurance benefits to the treating facility and providers. I understand that I may be billed for deductibles, co-payments, co-insurance, or non-covered services.

In the event of an emergency requiring additional or unforeseen procedures, I authorize the attending physician to perform such treatment as necessary for my safety.

Patient Consent Certification: By signing below I certify that I have read and understand this form, that the information I have provided is accurate to the best of my knowledge, and that I consent to the procedure and authorizations described herein.

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