Healthcare Post Operative Extension

HEALTHCARE POST OPERATIVE EXTENSION

Patient Information

Patient Name:

Date of Birth:     Gender:

Insurance Information

Procedure and Original Postoperative Period

Procedure / Surgery Performed:

Performing Surgeon / Provider:

Facility:     Surgery Date:

Original Postoperative Period Start:     End:

Requested Extension

Extension Requested Through:

Continued wound care
Ongoing intravenous antibiotics
Pain management / monitoring
Extended physical therapy / rehab
Other (specify below)

Current Clinical Status & Treatments

Home health nursing visits
Wound dressing changes
IV medication administration
Physical therapy services
Occupational therapy services
Other (specify below)

Risks, Benefits, and Alternatives

Continuing postoperative services beyond the originally-authorized period may provide ongoing wound surveillance, medication administration, and rehabilitation that can reduce the risk of complication or readmission. Risks include treatment-related complications, potential insurance non-coverage, and limitations to care not related to the underlying condition. Alternatives include outpatient clinic follow-up, self-care with instructions, or transfer of care to another provider. The patient may revoke this extension authorization at any time in writing, except to the extent that the provider has already relied upon the authorization.

I acknowledge that I have read and understand the risks, benefits, and alternatives described above.

I understand I may withdraw this authorization in writing, subject to limitations outlined above.

Privacy and Release

I authorize the treating provider and my insurer to exchange clinical and billing information necessary to review and approve the requested extension. I understand that information disclosed pursuant to this authorization may be re-disclosed by the recipient and may no longer be protected by privacy laws.

I authorize disclosure of relevant medical information for purposes of extension review and payment.

Provider Attestation (no signature required on this patient form)

Patient Consent and Certification

By signing below, I certify that the information provided on this Healthcare Post Operative Extension form is true and accurate to the best of my knowledge. I authorize continuation of the services and information exchange described above for the period requested or until the stated expiration date. I understand that payment responsibility may be determined by my insurer and that I remain responsible for charges not covered by insurance.

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