Healthcare Liability Consent Form

HEALTHCARE LIABILITY CONSENT FORM

Provider Name:    Facility:

Patient Information

Insurance Information

Medical History / Current Health Information

Description of Procedure / Services

Date of Service:    Performing Provider:

Risks, Benefits, Alternatives

The patient acknowledges that the nature, purpose, benefits, and material risks of the proposed procedure, including but not limited to infection, bleeding, scarring, adverse reaction to medications or anesthesia, nerve or tissue injury, and unforeseen complications, have been explained. Alternatives to the procedure, including no treatment and non-surgical options, have been discussed.

I acknowledge receipt of an explanation of the risks, benefits, and alternatives and understand that medicine and surgery are not exact sciences. I also understand that complications may require additional treatment or procedures.

I acknowledge that risks and alternatives were explained to me.

I have been given an opportunity to ask questions and they were answered to my satisfaction.

Assumption of Risk and Release of Liability

In consideration of receiving care and treatment, I voluntarily accept the risks associated with the procedure or service. I release and agree to hold harmless the Provider, facility, agents, employees and other personnel from liability for any claims, damages, losses, costs or expenses arising from complications, except to the extent caused by gross negligence or willful misconduct of the Provider or facility.

I understand that this release is a material inducement for the Provider and facility to perform the procedure. This release shall not be construed to limit any rights I have under applicable law for injuries resulting from gross negligence or willful misconduct.

I expressly assume the risks inherent in the described procedure and agree to the release and indemnification terms above.

HIPAA / Authorization to Use and Disclose Medical Information

I authorize the Provider and facility to use and disclose my protected health information as necessary for treatment, payment, and health care operations. I understand that this authorization permits disclosure to other health care entities involved in my care and to third-party payers as required for billing purposes.

This authorization expires on:

I authorize the use and disclosure described above and acknowledge receipt of the facility's privacy practices.

Right to Withdraw / Financial Responsibility

I understand that I may withdraw this consent at any time prior to the procedure by providing written notice to the Provider, except to the extent that action has already been taken in reliance on this consent. Withdrawal will not affect actions already taken.

I accept financial responsibility for services provided to me that are not covered by insurance and agree to pay charges for non-covered services, co-payments, co-insurance, and deductibles as required by the Provider's financial policy.

I acknowledge my right to withdraw consent as described above.

I accept financial responsibility as described above.

Certification and Acknowledgment

By signing below I certify that I have read (or had read to me) this consent form, that the information I have provided on this form is accurate to the best of my knowledge, that my questions have been answered, and that I consent to the procedure and the terms of release and authorization contained herein.

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