Healthcare Patient Combined Consents

HEALTHCARE PATIENT COMBINED CONSENTS

Patient Name:    Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History

Consent to Treatment

I hereby authorize licensed clinicians and staff of this facility to provide medical care, diagnostic procedures and treatment as deemed necessary for my diagnosis and treatment. I understand that no guarantees have been made regarding the results of any examination or treatment.

I consent to routine examination, diagnostic services and medically necessary treatment.

Consent for Specific Procedures and Risks

I understand that certain procedures carry risks, including but not limited to infection, bleeding, allergic reaction, adverse outcome, or need for additional treatment. The clinician has explained the nature, purpose, potential benefits and reasonably foreseeable risks of the proposed procedure.

I consent to the above procedure and acknowledge the risks and alternatives have been explained.

Authorization to Use and Disclose Protected Health Information (HIPAA Authorization)

I authorize the disclosure of my protected health information for purposes of treatment, payment, and healthcare operations, and for the specific purposes identified below. This authorization includes disclosure of history, diagnostic results, treatment records, and billing information unless specifically excluded below.

Categories of information to be disclosed (check as applicable):

Medical records, notes and lab results

Billing and insurance information

Mental health records (if applicable)

Recipient(s) authorized to receive information:

This authorization expires on: . If no expiration date is specified, this authorization will expire one year from the date signed.

I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer be protected by federal privacy regulations. I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it.

I authorize release of my medical records as described above.

Photography, Video and Audio Recording

I consent to clinical photography, video or audio recordings for the purpose of diagnosis, treatment, education, quality assurance, or documentation. Such recordings will be treated as protected health information.

I consent to photography/video/audio recording for clinical and administrative purposes.

Telemedicine / Electronic Communications

I understand that telemedicine involves the electronic transmission of medical information and that while reasonable safeguards will be used, there are risks such as technical failure, unauthorized access, or interception. I consent to telemedicine encounters, including exchange of medical information by telephone, email, secure messaging, video conferencing, or other electronic means.

I consent to participate in telemedicine and receive communications electronically.

Financial Responsibility and Assignment of Benefits

I accept financial responsibility for services provided. I authorize release of any medical information necessary to process claims and request that payment of authorized benefits be made directly to the provider. I understand I am responsible for co-payments, deductibles and non-covered services.

I authorize assignment of benefits and accept financial responsibility.

Patient Rights and Acknowledgment

I have the right to receive information about my care, to ask questions, to refuse treatment, and to be informed of the consequences of refusal. I acknowledge that I have had the opportunity to ask questions and receive answers regarding my care, consents, and authorizations contained herein.

Revocation and Expiration

This authorization may be revoked by providing a written notice to the facility's privacy officer. Revocation will not affect disclosures made in reliance on the authorization prior to receipt of the revocation. Unless otherwise specified above, this authorization will expire on the date indicated or one year from the date of signature.

Certification

I certify that the information I have provided is true and correct to the best of my knowledge. By signing below I acknowledge that I have read and understand this document, that my questions have been answered, and that I am signing voluntarily. If signing on behalf of the patient, I attest that I am authorized to do so and specify my relationship below.

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