Healthcare Medical Center Sign Off

HEALTHCARE MEDICAL CENTER SIGN OFF

Patient Information

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History

Consent for Treatment

I hereby authorize Healthcare Medical Center and its authorized providers to perform diagnostic and therapeutic procedures as deemed necessary. I have been informed of the nature of the proposed care or procedure, the anticipated benefits, common risks and material complications, and reasonable alternatives, including no treatment.

The patient acknowledges that not all risks can be listed here and that complications may include, but are not limited to, infection, bleeding, allergic reaction, and unforeseen adverse outcomes. The patient has had the opportunity to ask questions and to receive answers to their satisfaction.

I consent to the proposed treatment and related care as described above.

I acknowledge that risks, benefits, and alternatives were explained and I have had the opportunity to discuss them with the provider.

I understand I may withdraw consent at any time prior to the procedure by notifying the provider, except where withdrawal would jeopardize my safety.

HIPAA Authorization and Privacy Acknowledgment

I acknowledge receipt of the facility's Notice of Privacy Practices. I authorize Healthcare Medical Center to use and disclose my protected health information for treatment, payment, and healthcare operations in accordance with that notice and applicable law.

I acknowledge receipt of the Notice of Privacy Practices.

I authorize the facility to leave appointment reminders and lab/results by voicemail, text, or email:

Release of Medical Records

I authorize Healthcare Medical Center to release medical records and information to the following recipient(s) for the stated purpose(s).

Financial Responsibility and Assignment

I accept financial responsibility for services provided by Healthcare Medical Center that are not paid in full by my insurance. I authorize payment of insurance benefits directly to the provider and authorize the release of information necessary to process claims. I understand that I am responsible for co-payments, deductibles, and non-covered services.

I accept financial responsibility as stated above.

I assign benefits to the provider and permit direct billing to my insurer when applicable.

Acknowledgment and Certification

By signing below I certify that the information provided on this form is true and complete to the best of my knowledge. I understand that intentional falsification may be grounds for denial of services. I consent to treatment and authorizations herein, and I understand my rights to refuse or withdraw consent as permitted by law.

I certify the statements above and accept the terms of this sign-off.

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