Healthcare Patient Consent Forms

Healthcare Patient Consent Form

Patient Information

Date of Birth:   Gender: Female Male Other

Insurance Information

Medical History

Consent for Treatment

I, the undersigned, authorize licensed physicians, nurses and allied health personnel of the facility to perform the diagnostic, therapeutic or surgical procedures described below. I understand that the nature of the proposed procedure, the anticipated benefits, and the reasonably foreseeable risks have been explained to me and that no guarantees have been made concerning the results.

Risks and potential complications may include, but are not limited to: infection, bleeding, adverse reaction to medication or anesthesia, scarring, failure to achieve desired result, and unanticipated injury. Specific risks relevant to the proposed treatment have been identified and explained to me by the treating clinician.

Alternatives to the proposed treatment, including the option of no treatment or non-surgical management, have been explained. I have had the opportunity to ask questions and all my questions have been answered to my satisfaction.

I understand that I may withdraw this consent at any time prior to the procedure by notifying the treating clinician. Withdrawal of consent will not affect any care provided prior to the withdrawal or any emergency care required thereafter.

HIPAA Authorization & Privacy Acknowledgment

I acknowledge receipt of the facility’s Notice of Privacy Practices. I authorize the facility and my health care providers to use and disclose my protected health information for treatment, payment, and health care operations as necessary to provide care. I understand that I may request restrictions on certain uses and disclosures, and such requests will be considered in accordance with applicable law.

I authorize the release of copies of my medical records, including mental health or substance use treatment records where applicable, to other health care providers and third-party payors as necessary for continuity of care and billing, except as restricted by state or federal law and except where I have specifically indicated otherwise below.

Authorization Details

This authorization for release of information and consent for treatment shall remain in effect until  or until revoked in writing by me, whichever occurs first.

I understand that I may revoke this authorization at any time by submitting a written revocation to the facility, but that revocation will not affect disclosures already made in reliance on this authorization.

Consent Confirmations

I have read and understand the information above or it has been read to me. I have been given the opportunity to ask questions and all questions have been answered.

I consent to the treatment, procedures, and release of information described in this form and authorize the named providers to proceed.

I understand that I am financially responsible for charges not covered by insurance and agree to pay amounts not covered by third-party payors.

Acknowledgment of Rights

I understand my rights to: receive a clear explanation of my care, obtain a copy of my medical record, request amendment of my record, request restrictions on disclosures, and receive an accounting of disclosures as provided by law. I understand that I may file complaints about privacy practices without retaliation.

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