Healthcare Mission Agreement

HEALTHCARE MISSION AGREEMENT

Patient Information

Patient Name:    Date of Birth:

Emergency Contact

Mission Details

Location:    Start Date:    End Date:

Insurance Information

Medical History

Are you pregnant?

Consent to Treatment and Acknowledgements

I, the undersigned patient, consent to evaluation and medical treatment by medical personnel participating in the mission described above. I understand that resources available during the mission may be limited, that services are provided on an episodic basis, and that continuity of care and long-term follow-up may not be available. I authorize clinicians to perform examinations, basic diagnostics (including point-of-care testing), minor procedures, and to administer medications as clinically indicated.

I understand the benefits and risks associated with the proposed services, including but not limited to allergic reaction, bleeding, infection, inadequate therapeutic response, and the possibility that further care may be required. I have had the opportunity to ask questions about the nature and purpose of the services and alternatives and have received satisfactory answers.

I consent to medical evaluation and treatment during the mission.
I consent to diagnostic testing (blood tests, rapid tests, imaging as available).
I consent to vaccinations or immunizations recommended during the mission.
I consent to minor procedures (wound care, suturing, I&D) if necessary.

Privacy, Use of Information and Photography

I acknowledge that information gathered during evaluation and treatment will be recorded in a medical record maintained by the mission organization. I authorize the use and disclosure of my protected health information for treatment, payment and health care operations as required for the mission’s clinical activities. I understand identifiable information will not be released except as required by law or with my separate written authorization.

Photography: I consent to the non-identifiable use of photographs for educational or program documentation purposes. I do not consent to identifiable photographs or publishing of my name.

Release and Assumption of Risk

I understand that participation in care provided during a mission entails inherent risks and that, to the fullest extent permitted by law, I release and hold harmless the mission organization, affiliated clinicians, volunteers, and sponsoring entities from claims, liabilities, or damages arising directly or indirectly from the provision of services, except for willful misconduct or gross negligence. I agree to be responsible for charges not covered by insurance and for arranging any necessary follow-up care.

Authorization and Expiration

This authorization for treatment and release is effective immediately and will remain in effect until: unless earlier revoked in writing by the patient.

Acknowledgment of Rights

I understand that I may withdraw this consent at any time by submitting written notice to the mission clinical lead, except to the extent that action has already been taken in reliance on this consent. Withdrawal does not affect disclosures made prior to revocation.

By signing below I certify that the information I have provided is accurate to the best of my knowledge, that I have had the opportunity to ask questions, and that I freely consent to the terms set forth in this agreement.

Sign Now