Healthcare Mount Sinai Consent Form

HEALTHCARE MOUNT SINAI CONSENT FORM

Patient Name:    Date of Birth:    Medical Record No.:

Patient Information

Insurance Information

Medical History

Pregnant or possibly pregnant:    Implanted medical device (pacemaker, neurostimulator, etc.):    If yes, specify:

Procedure / Treatment Consent

I authorize Mount Sinai Health System and its designated practitioners to perform the following procedure(s) or service(s):

The practitioner has explained the nature and purpose of the proposed procedure, the expected benefits, and the reasonably foreseeable risks and complications which may include, but are not limited to: infection, bleeding, damage to adjacent structures, scarring, pain, anesthetic complications, and potential need for further procedures. I understand that it is not possible to list every complication and that uncommon and unforeseeable complications can occur.

Infection   Bleeding   Nerve or tissue injury   Anesthesia-related complications   Need for blood transfusion

I understand that no guarantee or assurance has been made to me as to the results that may be obtained from the procedure or treatment and that the practitioner will rely on clinical judgment during the procedure to address conditions that may be discovered.

Anesthesia / Blood Products

I consent to the administration of anesthesia as necessary for the planned procedure, which may include local, regional, sedation, or general anesthesia. I understand the risks of anesthesia and that the anesthesiologist will discuss anesthesia options with me.

Blood products: I consent to the administration of blood and blood products if, in the judgment of the treating clinicians, this becomes necessary. If I decline blood products, I understand that treatment options may be limited and I accept the increased risk of complications.

Consent to anesthesia:    Consent to blood transfusion:

Release of Information and HIPAA Acknowledgement

I authorize Mount Sinai Health System to use and disclose my protected health information for treatment, payment, and health care operations in accordance with applicable law. I understand that this authorization permits disclosure to other providers, insurers, and entities directly involved in my care or payment, and that health information may include records related to communicable diseases, behavioral health, alcohol or substance abuse treatment, and HIV/AIDS where applicable.

Purpose of disclosure:    Authorization expires on:

I acknowledge that I have been offered the facility's Notice of Privacy Practices and that I have the right to revoke this authorization in writing at any time except to the extent that action has already been taken based on this authorization.

HIPAA acknowledgement:    Initials:

Patient Rights and Certification

I certify that I have read and understand this consent form or that it has been read to me, that the procedure, risks, benefits, and alternatives have been explained, and that I have had the opportunity to ask questions and have received satisfactory answers. I understand that I may withdraw this consent at any time prior to the procedure by notifying the treating practitioner, but that withdrawal of consent may have consequences for my care.

Interpreter required:    Language:

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