Healthcare Patient Medical Treatment Form

HEALTHCARE PATIENT MEDICAL TREATMENT FORM

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Other Prefer not to say

Insurance Information

Medical History

Chronic Conditions (check all that apply)

Diabetes    Hypertension    Heart disease    Asthma    Kidney disease

Proposed Treatment / Consent for Treatment

I hereby authorize the treating clinicians and associated staff to perform the treatment(s) described above. I understand that reasonable alternatives to the proposed treatment, including the option of no treatment, have been explained where applicable. I acknowledge receipt of an explanation of the anticipated benefits, the material risks and complications reasonably foreseeable with the proposed treatment, and the expected recovery process.

I understand that no guarantee has been made as to the result of care, and that unforeseen complications may occur which may require additional treatment. I acknowledge that I have had the opportunity to ask questions and that my questions have been answered to my satisfaction.

I authorize the staff to administer medications and perform procedures in accordance with the provider's professional judgment, and to share necessary health information with other treating professionals for the purpose of diagnosis, treatment, and continuity of care.

I understand I may withdraw this consent at any time prior to the commencement of treatment by notifying the treating clinician, subject to any safety or clinical considerations.

I acknowledge that I have read and understand the information above, that all my questions have been answered, and I consent to the proposed treatment.

Authorization to Use and Disclose Health Information (HIPAA)

I authorize the medical provider to use and disclose my protected health information as necessary for treatment, payment, and health care operations. This authorization includes disclosure to other healthcare providers, insurance carriers, and third-party service providers involved in my care or billing. I understand that information disclosed pursuant to this authorization may include medical records, diagnosis, treatment notes, and billing information.

I understand that I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance on this authorization. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by applicable privacy law.

I acknowledge that I have received or been offered the provider's Notice of Privacy Practices and that I understand my rights regarding my protected health information.

Additional Consents and Declarations

Do you have an advance directive, living will, or durable power of attorney for healthcare? Yes No

Patient Certifications

By signing below I certify that I am the patient or the patient’s lawful representative. I affirm that the information provided on this form is complete and accurate to the best of my knowledge. I authorize treatment and the release of my health information as stated above. I understand the financial responsibility for services rendered and agree to pay applicable charges according to the provider's policies.

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