Healthcare Patient Consent to Care Form

Healthcare Patient Consent to Care Form

Patient Information

Date of Birth:    Gender:

Primary Phone:    Secondary Phone:

Relationship:    Phone:

Insurance Information

Policy/ID Number:    Group Number:

Medical History & Current Health

Are you pregnant or breastfeeding?   Yes   No

Consent to Treatment

I, the undersigned, authorize the healthcare providers, their agents and staff to provide medical treatment and care as deemed necessary for my health. Patient Name:

Description of proposed treatment or procedure(s):

I acknowledge that the following have been explained to me in terms I understand:

• Nature and purpose of the proposed treatment, expected benefits, and the approximate duration of therapy.
• Material risks and potential complications, including but not limited to infection, bleeding, allergic reaction, and treatment failure.
• Reasonable alternatives to the proposed treatment, including the option of no treatment and associated risks of refusal.

By checking the box below I provide informed consent for the proposed treatment and related diagnostic procedures:

I consent to the treatment, procedures, tests and care described above and authorize personnel to perform such care as necessary.

I understand that no guarantee has been made to me regarding the outcome of treatment. I may withdraw consent at any time by notifying my treating provider, except when withdrawal would create immediate risk or harm.

Authorization to Release Information and Billing Assignment

I authorize the release of medical information necessary to process claims and authorize payment of benefits to the provider. This authorization includes release of records to insurers, billing agents, and other entities as necessary for claims processing and payment.

I authorize release of medical information and assign insurance benefits to the provider.

HIPAA Privacy Acknowledgment

I acknowledge that I have received, been offered, or been informed of the availability of the provider's Notice of Privacy Practices that describes how my health information may be used and disclosed, and rights I have regarding my protected health information under applicable law.

I acknowledge receipt of the Notice of Privacy Practices.

Authorization Term and Expiration

This authorization is valid until: . If no date is provided, this authorization will remain in effect until revoked in writing.

Patient Statements and Certification

I certify that the information I have provided is true and complete to the best of my knowledge. I have had the opportunity to ask questions and have received answers to my satisfaction. I understand that I am financially responsible for any services not covered by insurance.

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