Healthcare Release Slip

HEALTHCARE RELEASE SLIP

Patient Name:   Date of Birth:

Patient Information

Insurance Information

Medical History (for release record)

Release Details

Date of Release:   Time:

Attending Physician:

Discharged to home    Transferred to another facility    Left Against Medical Advice    Other:

Authorization and Release

By signing this Healthcare Release Slip, I affirm that I am the patient named above or am lawfully authorized to act on the patient's behalf. I acknowledge that the information contained in this form is accurate to the best of my knowledge and that I have been informed of the patient's condition at the time of release and the recommended aftercare. I understand that the healthcare facility and its staff have provided their professional recommendations and that I accept responsibility for decisions to decline or delay recommended treatment.

I hereby release, discharge, and hold harmless the healthcare facility, its employees, agents, and representatives from any claims, liability, or causes of action that may arise from or relate to my decision to be released as documented herein, including but not limited to complications resulting from refusal of recommended treatment. This release includes claims based on negligence except where prohibited by law.

Financial Responsibility: I accept financial responsibility for services rendered through the date of release and agree to cooperate with billing and collection policies of the facility. I understand that insurance payments do not relieve me of any obligation for charges not paid by insurance.

Authorization to Release Information: I authorize the release of medical information necessary to process claims and to coordinate follow-up care or referrals. This authorization expires on: unless revoked in writing earlier. I understand that revocation will not affect disclosures made prior to receipt of the revocation.

HIPAA / Privacy Acknowledgment

I acknowledge that I have been offered a copy of the facility's Notice of Privacy Practices and that I understand how my protected health information may be used and disclosed for treatment, payment, and healthcare operations. I authorize disclosure of my health information to the following persons or entities for the purpose of follow-up care or billing:

Patient initials acknowledging receipt of verbal discharge instructions:   Patient initials acknowledging understanding of potential risks of leaving facility:

Patient Statement

I understand that I may withdraw this release before it is acted upon by notifying the facility in writing. I have had the opportunity to ask questions regarding my condition, the recommended treatment, alternatives, and the risks of accepting or refusing care. My signature below certifies that I knowingly consent to this release and accept the terms described above.

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