Healthcare SSOP Form

HEALTHCARE SSOP FORM

Facility Name:   Department:   Attending Practitioner:

Patient Information

Insurance Information

Medical History

Procedure / Service Details & SSOP Checklist

The following SSOP pre-procedure verifications must be completed and initialed by authorized staff. Check each item to confirm completion.

Hand hygiene performed
Surgical / procedure site marked and verified
Allergy status verified with patient and chart
Antibiotic prophylaxis administered when indicated
Equipment and instruments sterilized / properly packaged
Implant/device checks completed (if applicable)
Blood products ordered / available (if indicated)

Risks, Benefits and Alternatives

I acknowledge that the procedure, its medically reasonable alternatives, and the material risks and benefits have been explained to me in terms I understand. I have had the opportunity to ask questions and they have been answered to my satisfaction. I understand that no guarantee has been made to me regarding outcome.

Patient Initials:    I acknowledge explanation of risks/benefits:

HIPAA / Privacy Acknowledgment

I acknowledge receipt of the facility's privacy practices and understand that my protected health information may be used or disclosed for treatment, payment, and healthcare operations as necessary for my care. I authorize the facility to discuss my care with the emergency contact and subscriber listed above unless I have explicitly restricted such disclosures in writing.

I specifically authorize disclosure of relevant medical information to personnel directly involved in the procedure and to insurers for claims processing:

Authorization and Expiration

I hereby authorize the attending practitioner and designated clinical staff to perform the procedure described above and to carry out the facility SSOP measures necessary for a safe procedure, including but not limited to use of implants, devices, sterile processing, imaging and laboratory testing as required.

I understand that this authorization may be revoked by me in writing at any time, except to the extent that action has been taken in reliance on this authorization. Revocation must be submitted in writing to the facility’s medical records department.

Representations and Certification

By signing below I certify under penalty of civil and criminal law that the information I have provided on this form is true and complete to the best of my knowledge. I consent to the performance of the procedure and to the SSOP measures described. I acknowledge that I have disclosed all known allergies, medications and prior adverse reactions to anesthesia or devices.

Staff Verification (Pre-Procedure)

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