Healthcare StaffCARE Form

Healthcare StaffCARE Form

Facility Name:    Location/Unit:

Patient Information

Date of Birth:    Gender: Male Female Other Decline to state

Primary Phone:    Secondary Phone:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy Number:    Group Number:

Assigned Staff and Care Team

Medical History

Care Preferences and Advance Directives

Do you have an advance directive or DNR order? Yes No

Consent to Treatment by Staff

I authorize the assigned healthcare staff, including nurses, resident physicians, allied health personnel, and supervised trainees, to provide the following care as indicated and appropriate to my clinical needs. I understand that trainees may be present during my care.

General medical care and assessments

Routine nursing care (wound care, vital signs, basic hygiene)

Medication administration as ordered by authorized clinicians

Minor procedures performed under local anesthesia (as clinically necessary)

Observation or treatment by students/trainees under supervision

Risks, Benefits and Alternatives

I acknowledge that staff-provided care involves potential risks, including but not limited to allergic reactions to medications, inadvertent injury, infection, or other adverse events. I understand the anticipated benefits include diagnosis, symptom relief, and treatment of my medical condition. Alternatives, including deferral of care or referral to other providers, have been explained to me as appropriate. I have had the opportunity to ask questions and have received satisfactory answers.

Right to Withdraw and Revocation

I understand that I may withdraw this consent at any time by providing written notice to the Facility Name listed above, except to the extent that action has already been taken in reliance on this consent. Withdrawal will not affect actions taken by staff prior to receipt of written revocation.

Authorization to Share Health Information

I authorize staff to disclose my protected health information to the following persons for purposes of coordination of care, billing, and treatment:

Authorization Expiration Date:    If no date provided, this authorization will expire twelve months from the date of signature.

I authorize disclosure of my medical information for the purposes specified above: Treatment Billing/Payment Operations/Quality Review

HIPAA Privacy Acknowledgment

I acknowledge receipt of the facility's privacy practices notice and understand how my protected health information may be used and disclosed in connection with the provision of care. I understand my rights under applicable privacy law to request restrictions and to request confidential communications.

I acknowledge receipt of the privacy practices notice.

Certification

By signing below I certify that I am the patient or am authorized to sign on behalf of the patient. I attest that the information provided on this form is true and accurate to the best of my knowledge. I consent to the provision of care as indicated above and authorize those actions described in this form.

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