Healthcare Participant Release Form

HEALTHCARE PARTICIPANT RELEASE FORM

Participant Information

Emergency Contact

Insurance Information

Medical History

Activity / Procedure Description

Description of activity/procedure:

Date(s) of participation:

Risks, Benefits, and Acknowledgments

I understand that participation in the described activity or procedure involves inherent risks, including but not limited to injury, illness, or exacerbation of pre-existing conditions. I acknowledge that no guarantee has been made as to the results or outcome. I have been provided an opportunity to ask questions and receive answers regarding the nature, risks, and anticipated benefits of participation.

By signing below, I knowingly and voluntarily assume all risks associated with my participation and release, discharge, and agree to hold harmless the facility, its officers, employees, contractors, agents, and affiliates from any claims, liabilities, damages, or expenses arising from my participation, except for willful misconduct or gross negligence.

Authorization to Provide Emergency Treatment

In the event of an emergency during participation, I authorize designated personnel to provide or arrange for immediate medical treatment and transport to an appropriate medical facility. I agree to be financially responsible for any emergency medical treatment provided.

Authorization to Release Medical Information

I authorize the release of my medical records, treatment information, and other protected health information to the following individual(s) or organization(s) for purposes related to participation, treatment, billing, and coordination of care:

This authorization includes release of records relating to diagnosis, treatment, billing, substance use disorder, HIV/AIDS-related information, and mental health records to the extent permitted by law, except as specifically limited here:

Authorization expiration date:

HIPAA Privacy Acknowledgment

I acknowledge receipt of the facility's Notice of Privacy Practices, and I understand my rights with respect to my protected health information. I understand that I may request restrictions on use and disclosure, and that any such request must be made in writing and will be considered but may not be agreed to in all circumstances.

Revocation and Certification

I understand that I may revoke this authorization at any time by providing written notice, except to the extent that action has already been taken in reliance on this authorization. I certify that the information provided on this form is true and accurate to the best of my knowledge.

Consent and Release Signature

By signing below I certify that I am the participant or the legally authorized representative of the participant. I have read and understand this Release and Authorization in its entirety, I have had an opportunity to ask questions, and I voluntarily consent to participation and to the uses and disclosures described herein.

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