Healthcare Release and Waiver

Healthcare Release and Waiver

Patient Information

Date of Birth:    Gender:    Phone:

Relationship:    Phone:

Insurance Information

Policy Number:    Group Number:    Subscriber Name:

Medical History

Are you pregnant or is there a possibility of pregnancy? Yes No

Description of Treatment / Procedure

Anticipated benefits and objectives:

Risks, Alternatives and Acknowledgments

I acknowledge that the nature, purpose, and potential risks and benefits of the proposed treatment or procedure have been explained to me in terms I understand. Risks may include, without limitation, infection, bleeding, scarring, allergic reaction, adverse reaction to medications or anesthesia, need for additional procedures, or in rare cases permanent disability or death.

Alternatives, including the option of no treatment, reasonable alternatives, and expected outcomes of those alternatives have been explained and I have had the opportunity to ask questions and receive answers to my satisfaction.

I understand that no guarantee or assurance has been made as to the results that may be obtained and that unforeseen complications may occur.

By signing below I voluntarily consent to the treatment described above and authorize the medical personnel to perform such procedures, administer anesthesia, and provide such care as they deem necessary.

Release, Waiver and Indemnification

In consideration of receiving medical services and treatment, I, for myself and on behalf of my heirs, executors, administrators, personal representatives and assigns, hereby release, waive, discharge and covenant not to sue the facility, its physicians, clinicians, agents, employees and contractors (collectively the "Released Parties") from any and all liability, claims, demands, actions and causes of action whatsoever for any loss, damage, injury, cost or expense, including attorney fees, arising out of or related to the care, treatment, or services provided, whether arising from the negligence of the Released Parties or otherwise, except for willful misconduct or gross negligence as defined by applicable law.

I expressly assume the risk of any such loss, damage, injury or expense and agree to indemnify and hold harmless the Released Parties from any claims, liabilities, damages, or expenses, including reasonable attorneys' fees, resulting from my actions or omissions, or from third-party claims related to my treatment, except to the extent caused by the Released Parties' willful misconduct or gross negligence.

Authorization to Use and Disclose Medical Information (HIPAA)

I authorize the Released Parties to use and disclose my protected health information to the extent necessary for treatment, payment, and healthcare operations. I authorize disclosure to insurance payors, other healthcare providers for continuity of care, and to persons I designate below.

I understand that I may revoke this authorization at any time by providing a written notice to the facility, except to the extent that action has already been taken in reliance on this authorization. This authorization expires on:

Miscellaneous Provisions

If any provision of this document is found to be invalid or unenforceable, the remaining provisions shall remain in full force and effect. This Release and Waiver shall be governed by the laws of the jurisdiction in which the facility is located. This document constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior agreements, representations, and understandings.

I certify that I have read and fully understand the terms of this Healthcare Release and Waiver, that all my questions have been answered to my satisfaction, and that I execute this document voluntarily.

Signature

If signing on behalf of the patient, indicate relationship and authority.

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