Healthcare RADT MDCP Stoller

HEALTHCARE RADT MDCP STOLLER

Patient Information

Male Female Other

Insurance Information

Medical History

Procedure Details — RADT MDCP Stoller Protocol

Procedure Name:    Scheduled Date:

Risks, Complications & Alternatives

I acknowledge that the RADT MDCP Stoller protocol is a specialized radiation-based therapeutic procedure and that the treating physician has explained the nature of the procedure, expected benefits, and reasonably foreseeable risks, including but not limited to: acute radiation reaction, skin changes, localized tissue fibrosis, infection, bleeding, nerve injury, impaired wound healing, inadvertent exposure to adjacent tissues, and potential long-term effects including secondary malignancy. I understand that complications may require additional treatment, hospitalization, or surgery.

Alternatives to the proposed procedure, which may include observation, medical management, alternative radiation techniques, or surgery, have been discussed. I understand that no guarantee has been made regarding the results of the procedure.

Consent and Authorization

By signing below I, (DOB: ), authorize the treating physician and clinical staff to perform the RADT MDCP Stoller procedure described above and any additional procedural steps that are reasonably necessary for the safe performance of the treatment.

I grant authority for administration of medications, intravenous access, intravenous contrast agents if required, and conscious sedation or general anesthesia if necessary, in accordance with the physician's judgment. I understand that anesthesia carries separate risks which have been explained to me.

I understand that I may withdraw consent at any time prior to commencement of the procedure without affecting my right to future care. Withdrawal of consent during the procedure may not be possible or safe.

I authorize the disclosure of necessary medical information to other health care providers involved in my care, to my insurer for claims and payment, and to personnel performing data collection or quality assurance related to the RADT MDCP Stoller protocol. This authorization includes release of diagnostic images, treatment notes, and pathology reports relevant to the procedure.

Privacy and HIPAA Acknowledgment

I acknowledge receipt of the facility's privacy practices. I understand that my protected health information (PHI) related to this procedure will be used for treatment, payment, and healthcare operations as described in those practices. I consent to electronic transmission of relevant PHI for scheduling, billing, and inter-provider coordination. I may revoke this authorization in writing at any time, except to the extent actions have already been taken in reliance upon it.

Additional Consents

I consent to clinical photography and/or video recording for documentation and treatment planning. I understand images may be used for education or quality assurance without personal identifiers, unless additional written permission is obtained. I consent to de-identified data derived from my treatment being used for research or protocol evaluation. Participation is voluntary and will not affect my clinical care.

Financial Responsibility

I understand that I am financially responsible for all charges not covered by insurance. I authorize release of information to my insurer and assign benefits to the treating facility as necessary for claim submission and adjudication.

Acknowledgment

By signing below I certify that I have read and fully understand this consent form, have had the opportunity to ask questions, and that all my questions were answered to my satisfaction. I agree to the performance of the RADT MDCP Stoller protocol as described above.

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