Healthcare Prior Notice and Consent Form

HEALTHCARE PRIOR NOTICE AND CONSENT FORM

Patient Name:    Date of Birth:    Medical Record #:

Patient Information

Emergency Contact

Insurance Information

Medical History

Notice of Procedure / Services to be Performed

Description of Procedure(s) / Service(s):

Scheduled Date of Procedure:

Risks, Benefits, and Alternatives

I acknowledge that the health care provider has explained the nature and purpose of the proposed procedure, the reasonably foreseeable risks and potential complications, and the anticipated benefits. Typical risks may include, but are not limited to: infection, bleeding, reaction to medications or anesthesia, scarring, persistent pain, need for additional procedures, and unforeseen complications. I understand that not all risks can be listed here and that the provider has discussed risks specific to my condition.

Reasonable Alternatives: The provider has explained alternative treatments, including the option of no treatment, and their relative risks and benefits.

Additional Authorizations (if applicable)

Authorization for Use and Disclosure of Protected Health Information

I authorize the release of my protected health information, including records related to the procedure described above, to personnel and entities involved in my care and to insurance carriers or other payors for purposes of treatment, payment and healthcare operations as necessary to process claims and coordinate care. I understand that my health information may be re-disclosed by the recipient and may no longer be protected by privacy law.

Revocation: I understand that I may revoke this authorization at any time by submitting a written revocation to the facility except to the extent that action has been taken in reliance on this authorization. Revocation will not affect disclosures already made in reliance on this authorization prior to receipt of the revocation.

HIPAA / Privacy Acknowledgment

I acknowledge that I have been offered or received the Notice of Privacy Practices that describes how the facility may use and disclose my protected health information and how I can access this information. I understand my rights with respect to my protected health information, including the right to request restrictions and the right to inspect and copy my health record.

Consent and Certification

By signing below I certify that: I am the patient or am authorized to consent on behalf of the patient; I have read and understand this form (or it has been read to me); the nature, risks, benefits and alternatives to the procedure have been explained to me; I have had the opportunity to ask questions and my questions have been answered; I consent to the procedure and related care described above; and I authorize disclosure of my health information as set forth in this form.

Sign Now