Healthcare Patient Consent Form for Connecticut Retina

HEALTHCARE PATIENT CONSENT FORM FOR CONNECTICUT RETINA

Clinic: Connecticut Retina. Patient Name: Date of Birth: Medical Record / Account #:

Patient Information

Insurance Information

Medical History

Do you have a bleeding disorder or take blood thinners?: Yes No

Are you pregnant or breastfeeding?: Yes No

Procedure / Treatment Consent

I acknowledge that the physician has explained the nature and purpose of the procedure, the expected benefits, and the potential risks and complications, which may include but are not limited to:

• Infection (endophthalmitis), bleeding, or inflammation;
• Retinal detachment or retinal tear;
• Loss of vision, partial or complete;
• Increased intraocular pressure or glaucoma;
• Cataract formation or progression;
• Allergic reaction to medications or anesthesia;
• Need for additional procedures or surgery.

No guarantee has been made as to the results. I understand that unforeseen events may occur and additional treatment may be necessary. I have had the opportunity to ask questions and have received answers that I understand.

I understand I have the right to refuse or withdraw consent at any time prior to the procedure by informing the treating physician or staff. I understand withdrawal of consent will not affect my right to future care.

I authorize Connecticut Retina and its physicians and staff to perform the procedure(s) described above and to provide such ancillary care, including administration of topical, local or injected anesthesia and medications, as may be necessary in the professional judgment of the treating provider.

Acknowledgement of risks explained: I acknowledge the risks listed above have been explained to me

Alternatives discussed (including no treatment and non-surgical alternatives): Yes No

Photography, Recording and Use of Information

I authorize Connecticut Retina to obtain and use clinical photographs, digital images, or video recordings for medical documentation, diagnosis, treatment planning, and quality assurance. I understand that images used for teaching or publication will exclude identifying information unless a separate written authorization is obtained.

Consent for photography: Yes No

HIPAA / Privacy Authorization

I authorize Connecticut Retina to use and disclose my protected health information for treatment, payment, and healthcare operations as necessary to provide care. I understand that this authorization permits disclosure of medical records to insurers or other third parties involved in payment or care coordination. I understand I may revoke this authorization in writing except to the extent that action has already been taken in reliance upon it.

I consent to messages regarding appointments, test results, and billing at the phone number listed: Yes No

Financial and Billing Authorization

I authorize Connecticut Retina to bill my insurance for services rendered and to release any information necessary for processing claims. I accept financial responsibility for charges not covered by insurance, including co-payments, deductibles, and non-covered services. I understand payment policies of the practice apply.

Assignment of benefits: I assign benefits to the provider and permit direct payment by my insurer

Authorization Period

This authorization will remain in effect until: or until revoked in writing by the patient, whichever occurs first.

Patient Acknowledgement and Consent

By signing below I certify that I am the patient or the patient's authorized representative. I have read (or had read to me) and understand the information on this form. I have had the opportunity to ask questions about the procedure, risks, benefits, and alternatives and my questions have been answered to my satisfaction. I consent to the proposed treatment and related care at Connecticut Retina.

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