Healthcare Sinus Proposal

HEALTHCARE SINUS PROPOSAL

Patient Name:    Date of Birth:    Provider:

Patient Information

Insurance Information

Prior authorization required:    Carrier pre-certification obtained:

Medical History

Bleeding disorder or anticoagulant therapy:    Currently on anticoagulant medication:    Pregnant or suspect pregnancy:    Current smoker:

Proposed Procedure & Estimate

Risks, Benefits, and Alternatives

The proposed sinus procedure is recommended to address the clinical findings described above. The benefits may include improved sinus drainage, reduced infection frequency, and relief of nasal obstruction. These benefits are not guaranteed.

Known and potential risks include, but are not limited to: bleeding, infection, scarring, negative reaction to anesthesia, cerebrospinal fluid leak, change in sense of smell, vision changes including blindness, need for revision surgery, and other unforeseen complications. Additional, unanticipated findings during surgery may require modification of the planned procedure; I authorize the surgeon to make such decisions as clinically necessary.

Reasonable non-surgical alternatives and conservative management options have been discussed, including medical therapy and observation. I understand I have the right to refuse the recommended procedure and that refusal may result in progression of my condition.

Authorization and Consent

By checking the boxes below and signing this document I certify that I have read and received explanations of the planned procedure, that my questions have been answered to my satisfaction, and that I voluntarily consent to the performance of the described sinus procedure, including any reasonable modifications or additional procedures necessary in the surgeon's judgment.

I consent to the proposed procedure and related care, including the use of necessary instruments and implants.

I consent to the administration of local or general anesthesia as required and accept associated risks.

I authorize clinical photographs and imaging for medical records and treatment documentation; I understand de-identified images may be used for teaching and quality assurance unless otherwise restricted in writing.

HIPAA / Privacy & Release of Information

I acknowledge receipt of the facility/provider's privacy practices and authorize the release of medical information to my insurer(s), other treating providers, and billing agents as necessary for treatment, payment, or healthcare operations. I understand that I may revoke this authorization in writing except to the extent information has already been disclosed based on this authorization.

I acknowledge and authorize the above release and authorization for use and disclosure of my protected health information.

Financial Responsibility

I understand that payment for services is my responsibility. I authorize assignment of benefits to the provider and consent to release billing information to recover payment. I accept responsibility for deductibles, co-pays, co-insurance, and charges not covered by my insurer.

Authorization Period and Revocation

This authorization is valid until the date below unless revoked earlier in writing. Revocation will not affect disclosures or actions taken prior to receipt of the revocation. If no expiration date is provided, this authorization expires one year from the date signed.

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