Healthcare Medical Waiver

HEALTHCARE MEDICAL WAIVER

Patient Information

Insurance Information

Medical History

Procedure / Activity Description

Description of procedure, treatment, or activity to be performed:

Expected date of procedure/treatment:

Assumption of Risk and Release of Liability

I, the undersigned patient named above, acknowledge that I have been informed of the nature of the procedure or activity described above, including foreseeable risks, complications, and probable consequences. I understand that complications may include, but are not limited to, infection, bleeding, adverse reaction to anesthesia or medication, nerve injury, and other unforeseen outcomes.

By signing this waiver I voluntarily assume all risks associated with the procedure or activity and agree to release, hold harmless, and indemnify the facility, its officers, employees, contractors, and agents from any and all liability, claims, demands, causes of action, or damages arising from or in connection with the procedure or activity, except for liability arising from gross negligence or willful misconduct.

Consent to Treatment and Emergency Care

I authorize the attending medical personnel to perform the procedure described and to provide such diagnostic and therapeutic services as in their professional judgment may be necessary. If an unforeseen medical emergency arises, I authorize emergency treatment, including hospitalization, as deemed appropriate by the provider.

I acknowledge that no guarantees have been made to me as to the results of the procedure or treatment.

HIPAA Privacy and Authorization

I acknowledge receipt of the facility's privacy practices and authorize the release of my health information for treatment, payment, and healthcare operations as necessary for the provision of care. I authorize the disclosure of protected health information to the persons and entities involved in my care or as required by law.

I consent to the following additional disclosures (check all that apply):

Authorization Period

This authorization and waiver is effective immediately upon my signature below and will remain in effect until unless earlier revoked in writing. Revocation will not affect actions taken in reliance on this authorization prior to receipt of the revocation.

Acknowledgements and Certifications

By signing below I certify that the information provided on this form is accurate and complete to the best of my knowledge. I have had the opportunity to ask questions and have received answers to my satisfaction. I understand that I may withdraw consent at any time as described above.

Additional Instructions / Patient Notes

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