Healthcare Preparation Document

HEALTHCARE PREPARATION DOCUMENT

Patient Information

Patient Name:    Date of Birth:    Gender:

Phone:    Email:

Relationship:    Phone:

Insurance Information

Policy/ID Number:    Group Number:    Subscriber Name:

Planned Procedure and Preparation Details

Procedure Date:    Arrival Time:    Facility / Clinic:

Pre-Procedure Instructions (Acknowledgement)

I acknowledge that I have received and understand the following instructions. I will follow them unless specifically excused in writing by the clinical team.

I will fast as instructed and will not eat solid food within the prescribed fasting period.

I will hold or take medications as directed by the provider (including anticoagulants, diabetic medications, and other prescribed drugs).

I will arrive at the scheduled time with a responsible adult to accompany me home if required.

Medical History & Current Medications

Consent, Risks, and Authorizations

By signing below, Patient Name: authorizes the performance of the planned procedure described above and any customary ancillary care reasonably required during the procedure. I understand that all medical and surgical procedures involve risk and that complications may occur including, but not limited to, infection, bleeding, adverse reaction to medications, anesthetic complications, and unforeseen outcomes. The performance of the procedure, its nature and purpose, commonly known risks, expected benefits, and reasonable alternatives (including no treatment) have been explained to me and I have had the opportunity to ask questions.

I understand that the practice of medicine and surgery is not an exact science and that no guarantee has been made to me as to the results of the procedure. I consent to administration of anesthesia or sedation as ordered by the treating practitioner. I further authorize the provider to take photographs or video for medical documentation, treatment planning, or quality assurance; such media will be maintained as part of the medical record consistent with applicable privacy protections.

I acknowledge my right to refuse the procedure or withdraw consent at any time prior to initiation of the procedure. If I am unable to participate in decision-making, the individual signing on my behalf represents that they are legally authorized to consent for me and will provide a copy of the documentation establishing authority upon request.

Authorization to Release Health Information and HIPAA Acknowledgement

I authorize the release of my protected health information to my insurance carrier and to any other health care providers as necessary for treatment, payment, or health care operations in connection with the procedure. I acknowledge receipt of the clinic's Notice of Privacy Practices and understand that, unless I object in writing, routine notifications regarding appointment reminders, billing, and treatment may be communicated to me by telephone, mail, or other customary methods.

This authorization for release of information remains in effect until: , or until revoked in writing by the patient, except to the extent that action has already been taken in reliance on my authorization.

I acknowledge that I have been offered or provided with the clinic's Notice of Privacy Practices.

Financial Responsibility

I understand that I am responsible for payment of charges not covered by my insurance. I authorize assignment of benefits to the provider and direct payment of insurance benefits to the provider where allowed. In the event of non-payment by my insurer, I accept primary responsibility for payment of all charges for services rendered unless otherwise prohibited by contract or law.

Acknowledgements and Patient Certifications

I certify that the information I have provided on this form is complete and accurate to the best of my knowledge. I have had an opportunity to ask questions and I understand the information provided. I understand that failure to follow pre-procedure instructions may result in postponement or cancellation of the procedure.

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