Healthcare Retina Proposal

HEALTHCARE RETINA PROPOSAL

Patient Information

Patient Name:    Date of Birth:

Insurance Information

Referring / Treating Physician

Medical & Ocular History

Proposed Retina Evaluation & Treatment Plan

Proposed Procedure:

Risks, Benefits, and Alternatives

I acknowledge that my treating physician has provided a clear explanation of the proposed retina treatment, including the nature of the procedure, expected benefits, reasonably foreseeable risks (which may include infection, bleeding, retinal detachment, cataract progression, elevated intraocular pressure, and potential loss of vision), and reasonable alternatives including observation and other medical or surgical options.

Estimated Fees & Financial Terms

The following is an estimate of anticipated professional and facility charges. These estimates are provided for planning purposes only and do not constitute a guarantee of final cost or insurance payment.

Financial Responsibility: The patient is responsible for any co-payments, deductibles, non-covered charges, and amounts not paid by insurance. By signing below, the patient authorizes release of information necessary to process claims and assignment of benefits to the treating practice where permitted.

Patient Acknowledgments (initial or check as applicable)

I have received an explanation of the proposed procedure, risks, benefits, and alternatives and had the opportunity to ask questions.

I authorize release of medical information to my insurer and assign benefits to the provider where applicable.

I understand that I may withdraw consent prior to the procedure without affecting my right to future care.

HIPAA / Privacy Acknowledgement

I acknowledge receipt of the practice's privacy notice describing how my protected health information may be used and disclosed for treatment, payment, and healthcare operations, and I understand my rights to request restrictions and to receive confidential communications.

I acknowledge that I have received or been offered the privacy notice.

Authorization & Expiration

This proposal serves as documentation of the recommended evaluation and treatment. Authorization for release of information and assignment of benefits, if signed, shall remain effective until the conclusion of care related to this condition or until revoked in writing. If an expiration date is desired, indicate here:

Additional Notes / Clinical Instructions

Acknowledgment and Consent

By signing below, I certify that I am the patient (or authorized guardian), that the information provided is accurate to the best of my knowledge, that I have read and understand this retina proposal, and that I consent to the evaluation and treatments as indicated above. I understand that no guarantee or warranty has been made as to the results of treatment.

Sign Now