Healthcare Patient Consent Package

HEALTHCARE PATIENT CONSENT PACKAGE

Patient Information

Patient Name:    Date of Birth:

Gender: Male Female Other

Emergency Contact

Insurance Information

Medical History

Tobacco Use: Yes No    Alcohol Use: Yes No

Consent for Treatment

I, the undersigned, authorize the identified healthcare providers, their assistants, and other personnel to perform the procedure(s) and provide such treatment as deemed necessary. Procedure / Service:

Treating Provider:    Proposed Date of Service:

I acknowledge that the nature and purpose of the proposed treatment, material risks (including but not limited to infection, bleeding, adverse reaction to medication or anesthesia, nerve or organ damage, and death where applicable), anticipated benefits, and reasonable alternatives (including no treatment) have been explained to me in a manner I understand. I understand that no guarantee has been made about the outcome or success of the treatment.

I understand that I may withdraw my consent at any time prior to the initiation of the procedure, and that continuing or withdrawing from treatment may have medical consequences. I have had the opportunity to ask questions and all questions have been answered to my satisfaction.

Anesthesia and Sedation: The risks, benefits, and alternatives to anesthesia or sedation, when applicable, have been explained. I consent to administration of anesthesia or sedation as required for the procedure.

I consent to routine photographic, video, or audio recordings for medical record, diagnostic, treatment, and educational purposes unless I indicate otherwise: Permit   Do not permit

Financial Responsibility & Assignment

I accept financial responsibility for charges not covered by my insurance and authorize payment of benefits directly to the provider where applicable. I authorize the release of medical information necessary to process claims, and I permit a copy of this authorization to be used in place of the original.

HIPAA / Privacy & Release of Medical Information

I acknowledge receipt of the facility's Notice of Privacy Practices and understand that my protected health information (PHI) may be used and disclosed for treatment, payment, and healthcare operations. I authorize the release of my PHI, including records relating to treatment, diagnosis, billing, and insurance, to persons and entities involved in my care and payment for my care.

I authorize release of my medical records to the following individual(s) or entity(ies):

Purpose of Release:

I understand that I may revoke this authorization in writing at any time, except to the extent that action has been taken in reliance on it. This authorization will remain in effect until the expiration date specified above or until revoked in writing.

Acknowledgment and Certification

By signing below I certify that I have read and fully understand this consent package, that the information I have provided is accurate to the best of my knowledge, and that I consent to the procedures and uses and disclosures described above. I further certify that no guarantee or assurance has been made to me as to the results that may be obtained.

If signing on behalf of the patient, indicate your legal relationship to the patient:

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