Healthcare Liability Release Form

HEALTHCARE LIABILITY RELEASE FORM

This Healthcare Liability Release Form documents the understanding and agreement between the medical provider and the undersigned patient or authorized representative regarding potential risks, release of claims, and limited authorization related to the provision of medical care or participation in clinical activities.

Patient Identification

Patient Name:

Date of Birth:    Gender:

Insurance Information

Medical History

Procedure / Activity Description

Scheduled Date of Procedure/Activity:

Risks, Acknowledgment, and Assumption of Risk

I acknowledge that I have been informed of the nature of the proposed procedure or activity, including the reasonably foreseeable risks, complications, and potential adverse outcomes, which may include but are not limited to infection, bleeding, allergic reaction, organ injury, failure to achieve desired results, permanent impairment, or death. I understand that the practice of medicine and clinical procedures is not an exact science and that no guarantees have been made concerning results.

I voluntarily assume full responsibility for all risks associated with the procedure or activity described above and accept the possibility of unforeseen risks.

I have read and discussed the risks and benefits of the procedure with a qualified provider and my questions have been answered to my satisfaction.

My consent to proceed is freely given and is not the result of coercion, misrepresentation, or fraud.

Release, Waiver, and Indemnification

In consideration of receiving care and being permitted to participate in the procedure or activity described herein, I, on behalf of myself, my heirs, assigns, personal representatives and next of kin, hereby release, waive, discharge and covenant not to sue the healthcare provider, its physicians, nurses, staff, agents, contractors, and affiliated organizations (collectively, "Released Parties") for any and all liability, claims, demands, actions or causes of action, whether in tort, contract, or otherwise, arising out of or related to any loss, damage, injury or death that may be sustained by me, whether caused by the negligence of the Released Parties or otherwise, except for acts or omissions constituting gross negligence or willful misconduct as defined by applicable law.

I agree to indemnify, defend and hold harmless the Released Parties from and against any and all claims, liabilities, losses, costs and expenses (including reasonable attorneys' fees) arising from my acts or omissions in connection with the procedure or activity, except where such claims result solely from the gross negligence or willful misconduct of the Released Parties.

Emergency Treatment Authorization

If, in the judgment of the treating provider, emergency medical treatment is required for an injury or condition that arises in connection with the procedure or activity, I authorize such treatment as may be necessary to preserve my health and safety. I understand that reasonable efforts will be made to contact my emergency contact prior to or during emergency treatment when practicable.

Privacy Acknowledgment

I acknowledge receipt of the provider's privacy practices and understand that protected health information necessary for treatment, payment, and healthcare operations related to the procedure may be used and disclosed in accordance with applicable law. I authorize the release of medical information relevant to my care to other providers, payers, and institutions as reasonably necessary.

I acknowledge the privacy practices and consent to disclosure as stated above.

Authorization Duration and Withdrawal

This release and authorization is effective on the date signed below and shall remain in effect until the Authorization Expiration Date entered below, unless earlier revoked in writing by the undersigned. A written revocation will not affect actions taken in reliance on this release prior to receipt of the revocation by the provider.

Authorization Expiration Date:

Representative / Guardian

If the undersigned is signing as a parent, legal guardian, or authorized representative, provide relationship and authority to sign.

Certification: By signing above I certify that I am the patient or an authorized representative of the patient, that I have read and understand this Healthcare Liability Release Form, that the information provided is true and correct to the best of my knowledge, and that I have the authority to execute this release on behalf of the patient where applicable.

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