Healthcare Response Document

HEALTHCARE RESPONSE DOCUMENT

Patient Information

Date of Birth:    Gender:

Primary Phone:    Alternate Phone:

Insurance Information

Policy Number:    Group Number:

Medical History

Encounter Summary / Clinical Assessment

Date of Contact / Service:    Clinician:

Recommended Treatment / Patient Response

Patient Response (select one):
I accept the recommended treatment and authorize proceeding.
I decline the recommended treatment at this time.
I request additional information and will defer decision until informed consent provided.

Risks, Benefits, and Alternatives

The clinician has explained the nature of the proposed treatment, anticipated benefits, material risks (including but not limited to infection, bleeding, allergic reaction, scarring, and anesthesia-related complications where applicable), and reasonable alternatives, including the option of no treatment. I understand that complications may occur even with reasonable care.

I acknowledge that no guarantee has been made about the results of the proposed treatment, and that I have had the opportunity to ask questions and receive answers to my satisfaction.

Patient initials acknowledging discussion of risks and alternatives:

Authorization for Communication and Records

I authorize the health care provider and staff to communicate with me at the phone numbers, email, or address provided above regarding appointments, treatment, and billing. I understand that electronic communications may not be fully secure.

I authorize release of my medical records related to the treatment described above to the following person(s) or entity(ies), for the purpose(s) described below:

Authorization Expiration Date:

I understand that I may revoke this authorization at any time by submitting a written revocation to the provider, except where action has already been taken in reliance on this authorization. Revocation does not apply to information already released in response to this authorization.

HIPAA Privacy Acknowledgment

I acknowledge that I have been offered a copy of the Provider's Notice of Privacy Practices, which describes how my medical information may be used and disclosed and how I can access this information. I understand my rights with respect to protected health information and that I may request restrictions or confidential communications as permitted by law.

I acknowledge receipt of the Notice of Privacy Practices:

Certifications and Patient Acknowledgment

By signing below, I certify that I am the patient named above or the patient's legally authorized representative. I certify that the information I have provided on this document is complete and accurate to the best of my knowledge. I authorize the release of medical information as set forth herein and authorize the treatment as indicated if I have consented to treatment above.

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