Healthcare Release to Treatment

HEALTHCARE RELEASE TO TREATMENT

Patient Name:   Date of Birth:

Patient Information

Insurance Information

Medical History

Are you pregnant or attempting pregnancy?

Authorization to Treat

I, the undersigned, hereby authorize physicians, nurses and other authorized healthcare personnel of the treating facility to provide medical care, diagnostic tests and treatment as deemed necessary for my medical condition. This authorization includes routine diagnostic procedures, medication administration, emergency treatment, and any other care reasonably related to the treatment plan described below.

I acknowledge that my provider has explained the nature, purpose, expected benefits, and material risks associated with the proposed treatment. I understand that risks may include, but are not limited to, infection, bleeding, allergic reaction, unintended outcomes, or the need for additional procedures. I have been given the opportunity to ask questions and all my questions have been answered to my satisfaction.

Alternatives to the proposed treatment, including the option of no treatment or referral to another provider, were discussed with me. I understand that medicine is not an exact science and that no guarantees have been made regarding results.

Scope of Authorization (check all that apply)

I authorize routine diagnostic tests and laboratory procedures necessary for diagnosis and treatment.
I authorize administration of medications as prescribed by my provider.
I authorize administration of local or general anesthesia if required for the procedure.
I authorize emergency treatment, including life-saving procedures, if a life-threatening event occurs during care.
Other (describe):

Authorization to Release Information

I authorize the disclosure of my protected health information to the following individual(s) for purposes of coordinating care, scheduling, and billing:

This authorization permits disclosure of information including diagnosis, treatment, billing, and limited mental health or substance use records as necessary to carry out the purposes described. I understand that information disclosed pursuant to this authorization may be re-disclosed by the recipient and may no longer be protected by law.

HIPAA / Privacy Acknowledgment

I acknowledge that I have been offered or provided the healthcare facility's privacy practices and that I understand how my health information may be used and disclosed to carry out treatment, payment, and healthcare operations. I authorize the use and disclosure of my protected health information as described above and consistent with applicable law.

I acknowledge receipt of privacy practices and authorize disclosure as described.

Revocation and Expiration

I understand that I may revoke this authorization at any time by delivering a written notice of revocation to the treating facility's medical records department, except to the extent that action has already been taken in reliance on this authorization. This authorization will expire on: unless earlier revoked in writing.

Financial Responsibility and Assignment

I understand that I am financially responsible for all charges for services provided to me that are not covered by insurance. By signing below I authorize my insurer to pay benefits directly to the treating facility or provider and assign benefits where applicable. I agree to pay any patient responsibility including co-pays, deductibles, and non-covered services.

I authorize assignment of insurance benefits to the provider as necessary for payment.

Voluntary Consent

I confirm that I have read (or had read to me) and understand the information on this form. I have had the opportunity to ask questions and have received satisfactory answers. I consent to the treatment described above and to the release of information as necessary for treatment, payment, and healthcare operations.

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