Healthcare SPC Form

HEALTHCARE SPC FORM

Patient Information

Patient Name:    Date of Birth:

Gender:    Home Phone:

Insurance Information

Medical History

Special Procedure Consent (SPC)

Procedure / Service to be performed:

I acknowledge that the proposed procedure has been explained to me including the intended benefits, material risks and common complications, and reasonable alternatives. I understand that no guarantee has been made with respect to the outcome.

Authorization and Financial Responsibility

By signing below I authorize the provider, clinicians and designated personnel to perform the procedure described above and to administer such anesthetics, medications and tests as deemed necessary. I authorize release of my medical information to insurance carriers and other providers for treatment, payment and healthcare operations, and assign benefits to the provider where applicable.

I accept financial responsibility for charges not covered by my insurance, including deductibles, co-payments and services determined to be non-covered. I understand I may be billed directly for those charges.

HIPAA / Privacy Acknowledgment

I acknowledge that I have received or been offered the facility's Notice of Privacy Practices describing how my protected health information may be used and disclosed. I authorize the use and disclosure of my health information for treatment, payment, and health care operations as described in that notice.

Release to individuals: Name(s) of persons permitted to receive information about my care:

Authorization Duration

This authorization is valid until:    unless earlier revoked in writing or superseded by a later dated authorization.

Revocation: I understand I may revoke this authorization at any time by submitting written notice, except to the extent that action has already been taken in reliance on it. I understand that revocation will not affect disclosures made prior to receipt of the revocation.

Sign Now