Healthcare Mediport Offer

HEALTHCARE MEDIPORT OFFER

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance Information

Clinical Indication and Procedure Description

Clinical Indication:

Offer Terms and Financial Estimate

Facility:    Primary Provider:

Estimated Device Cost: $    Estimated Facility & Procedure Fee: $

Patient Responsibility (estimated): $

Payment Terms:

Medical History

Risks, Benefits, and Alternatives

Risks: Insertion of a mediport carries risks including, but not limited to, infection, bleeding, thrombosis, catheter malposition or fracture, pneumothorax, device malfunction, allergic reaction, and need for additional procedures. The list above is not exhaustive and additional complications may occur.

Benefits: A mediport may provide durable access for intravenous therapy, chemotherapy, frequent blood draws, and systemic treatments while reducing peripheral venipuncture. Expected benefits will be individualized based on clinical condition.

Alternatives: Alternatives include peripheral intravenous access, peripherally inserted central catheter (PICC), tunneled central venous catheter, or foregoing central venous access. Each alternative carries its own risks and benefits.

Consent, Authorization, and Acknowledgements

By signing this Healthcare Mediport Offer, the Patient authorizes the proposed mediport insertion and associated procedures, including pre-procedure evaluation, imaging, anesthesia as required, and post-procedure care. The Patient acknowledges that the provider has explained the nature of the procedure, expected benefits, material risks, and reasonable alternatives, and has had the opportunity to ask questions.

Right to Withdraw: The Patient understands the right to withdraw consent at any time prior to commencement of the procedure without penalty. Withdrawal after initiation may increase clinical risk.

Authorization Expiration Date:

Financial Responsibility and Assignment

The Patient authorizes assignment of benefits to the treating provider and facility and understands responsibility for deductibles, co-payments, co-insurance, and amounts not covered by insurance. The Patient agrees to cooperate with billing and payment processes and to notify providers of insurance changes prior to the procedure.

Verification and Acknowledgement

I certify that the information I have provided on this form is true and complete to the best of my knowledge. I have disclosed known allergies, medications, prior surgeries, and chronic conditions that may affect the procedure. I consent to the proposed treatment and accept the offer terms set forth above.

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