Healthcare Signed Document

Healthcare Signed Document

Patient Information

Date of Birth:    Gender:

Insurance Information

Medical History

Procedure / Treatment Authorization

I authorize the health care providers and staff of the facility to perform the following procedure(s) or treatment(s):

Primary clinician performing procedure:    Proposed date of service:

I acknowledge that the benefits, material risks, and reasonable alternatives to the proposed procedure have been explained to me in terms I can understand. I understand that no guarantee has been made as to the results of the procedure. The risks include, but are not limited to, infection, bleeding, allergic reaction, complications from anesthesia and procedural complications specific to the procedure described above. I have had the opportunity to ask questions, and my questions have been answered to my satisfaction.

Alternatives discussed: Alternatives were explained and considered.    No reasonable alternatives exist.

I understand that I may withdraw or revoke this consent at any time prior to the procedure by providing written notice, except where the withdrawal would jeopardize clinical care or safety.
I understand my right to withdraw consent prior to treatment.

HIPAA Authorization & Privacy

I authorize the release of my protected health information as described below for the purposes indicated. I understand that information disclosed pursuant to this authorization may include records relating to diagnosis, treatment, billing, and payment. I understand that this authorization is voluntary and that treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing this authorization unless allowed by law.

Medical records    Billing and payment records    Laboratory results    Imaging reports

Expiration of authorization:    I understand that I may revoke this authorization in writing at any time, except to the extent that disclosures have already been made in reliance on this authorization.

Redisclosure warning: Information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer protected by federal privacy regulations.

Acknowledgement: I acknowledge that I have received or been offered a copy of the facility's Notice of Privacy Practices.

Patient Certification

By signing below I certify that I am the patient or duly authorized to act on behalf of the patient. I have read and understand the information on this form, all of my questions have been answered, and I voluntarily consent to the treatment and release of information as described above. I understand that I may request a copy of this signed authorization.

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