Healthcare Liability Release Agreement

HEALTHCARE LIABILITY RELEASE AGREEMENT

Patient and Provider Information

Patient Name:    Date of Birth:

Phone:    Gender:

Date of Service:

Insurance Information

Medical History

Procedure / Treatment and Consent

By checking the boxes below and signing this document, I acknowledge and agree to the following statements and release provisions.

I have been informed of the nature, purpose, expected benefits, and material risks associated with the proposed treatment and have had the opportunity to ask questions that have been answered to my satisfaction.

I understand reasonable alternatives to the proposed treatment, including the option of no treatment, and the material risks of such alternatives.

Release, Waiver and Indemnification

In consideration of receiving medical care and access to the Provider's facilities and services, Patient hereby RELEASES, WAIVES AND DISCHARGES Provider, its physicians, nurses, employees, contractors, agents, successors and assigns (collectively, Released Parties) from any and all claims, demands, causes of action, liabilities, costs and expenses, including attorneys' fees, arising out of or in connection with the treatment described above, whether known or unknown, foreseen or unforeseen, except to the extent caused by the Released Parties' gross negligence or willful misconduct as determined by a court of competent jurisdiction.

I agree to defend, indemnify and hold harmless the Released Parties from and against any third-party claim, demand or action arising from my actions or omissions in connection with the treatment, except to the extent the claim arises solely from gross negligence or willful misconduct by the Released Parties.

I understand this release does not affect my right to pursue claims for gross negligence or willful misconduct and does not waive any rights that cannot be waived by law.

HIPAA Authorization and Privacy Acknowledgment

I authorize the Provider to use and disclose my protected health information for purposes of treatment, payment, and healthcare operations. I authorize the release of medical and billing records to insurers, other healthcare providers, and agents involved in my care. This authorization will expire on: unless earlier revoked in writing.

I have received or been provided the Provider's Notice of Privacy Practices and understand my rights regarding the use and disclosure of my health information.

Financial Responsibility and Miscellaneous Provisions

I accept financial responsibility for charges not covered by insurance and agree to pay all copayments, deductibles, and balances in accordance with Provider policies.

If any provision of this Agreement is held invalid, illegal, or unenforceable, the remaining provisions shall remain in full force and effect. This Agreement contains the entire understanding between the parties with respect to the subject matter and supersedes all prior oral or written agreements.

Emergency Contact

Minor / Guardian

I am signing on behalf of the patient as parent or legal guardian. If checked, provide guardian information below.

Acknowledgment and Certification

I certify that the information I have provided on this form is true and complete to the best of my knowledge. I have read and fully understand this Liability Release Agreement, including the nature of the treatment, the release and indemnification provisions, and the HIPAA authorization. This consent and release apply to the treatment described above and to any related treatments or follow-up care arising therefrom.

I have read and understand the statements above and agree to them voluntarily.

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