Healthcare Medical Liability Release

Healthcare Medical Liability Release

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance Information

Medical History

Description of Treatment or Procedure

Provider/Facility:

Scheduled/Planned Date of Procedure:

Risks, Benefits and Alternatives

I acknowledge that the provider has explained the nature and purpose of the proposed treatment or procedure, the material risks and complications (which may include but are not limited to infection, bleeding, scarring, need for additional treatment, adverse reaction, and death), the expected benefits, and reasonable alternatives including no treatment. I understand that no guarantee has been made as to the results of the treatment or procedure.

I have had the opportunity to ask questions about the procedure, the risks, benefits and alternatives, and my questions have been answered to my satisfaction: I acknowledge

Assumption of Risk and Release of Liability

In consideration of receiving the described treatment or procedure, I voluntarily assume all known and unknown risks associated with the treatment, whether foreseeable or unforeseeable. I release, waive, discharge and covenant not to sue the provider, its physicians, employees, agents, contractors and affiliated entities (collectively "Released Parties") for any and all claims, demands, losses, liabilities, or causes of action arising out of or relating to the treatment, including claims based on the negligence of any Released Party, except where prohibited by applicable law.

I further agree to indemnify and hold harmless the Released Parties from and against any and all liabilities, claims, actions, suits, demands, damages, expenses and costs (including reasonable attorneys' fees) incurred as a result of my participation in the treatment or any breach of this Release, to the extent permitted by law.

I understand that this Release is intended to be broad and inclusive and that if any portion is held invalid, the remainder shall continue in full legal force and effect.

I acknowledge that I have read and understand this Release and that I am signing freely and voluntarily. I understand that I may consult an attorney before signing this document.

HIPAA / Privacy Acknowledgment

I acknowledge that the provider's Notice of Privacy Practices has been made available to me and that I understand how my protected health information may be used and disclosed for treatment, payment, and healthcare operations. I authorize the release of medical and billing information to my insurer, other treating providers, and as required by law in connection with the treatment described above.

I acknowledge and consent to the foregoing.

Emergency Treatment

In the event of an emergency arising out of the procedure, I authorize the provider to take those emergency measures that, in the professional judgment of the provider, are necessary to preserve my health and safety. I understand that efforts will be made to contact my emergency contact listed above.

I consent to emergency treatment as described above.

Authorization Term and Revocation

This Release and Authorization shall remain in effect until revoked in writing by me, except that revocation will not affect any action taken by the Released Parties prior to receipt of the written revocation. Expiration Date (if any):

Patient Certification

By signing below I certify that I am the patient or that I am authorized to sign on behalf of the patient. I have read and fully understand this Medical Liability Release and that I have been given the opportunity to ask questions and to receive answers satisfactory to me.

Sign Now