Healthcare Supplement Consent Form

HEALTHCARE SUPPLEMENT CONSENT FORM

Patient Name:    Date of Birth:

Patient Information

Insurance / Billing Information

Medical History

Supplement Details (to be completed by provider)

Risks, Benefits, and Alternatives

I have been informed of the potential benefits of the recommended supplement(s), which may include improved nutritional status or symptomatic relief as clinically indicated. I understand there is no guaranteed outcome.

I have been advised of reasonably foreseeable risks, which may include but are not limited to: gastrointestinal upset, allergic reaction, interaction with prescription or over-the-counter medications, alteration of laboratory values, and rare but serious adverse reactions. I understand additional, unknown risks may exist.

Alternatives to the proposed supplementation, including no supplementation or other therapeutic options, have been explained to me and I have had the opportunity to ask questions about alternatives and potential outcomes.

I will promptly notify my provider of any new medications, supplements, pregnancy, breastfeeding status, or changes in medical condition that may affect the safety of the supplement regimen.

Consent and Authorization

By checking the box below and signing this form I certify that I have read and understand the information provided in this form, that my questions have been answered to my satisfaction, and I voluntarily consent to the recommendation, dispensing, or administration of the specified supplement(s) by the treating clinician.

I authorize the healthcare provider to recommend, dispense, or administer the above-listed supplement(s) as part of my care and to document this authorization in my medical record.

I authorize the release of relevant medical information to my insurer, as necessary, for billing and payment of services related to the supplement recommendation or administration. I accept financial responsibility for services not covered by my insurer.

I acknowledge that no warranty or guarantee has been made to me regarding the results of the supplement(s) and that adverse effects may occur.

Privacy and HIPAA Acknowledgment

I acknowledge that I have been offered a copy of the Notice of Privacy Practices describing how my protected health information may be used and disclosed. I consent to the use and disclosure of my health information as described above for treatment, payment, and healthcare operations related to this consent.

I acknowledge receipt (or offer of receipt) of the privacy notice and consent to the uses described above.

Duration, Revocation, and Documentation

This authorization is valid until: unless sooner revoked in writing. Revocation will not affect actions already taken in reliance on this authorization prior to receipt of revocation.

I understand that I may withdraw this consent at any time by providing written notice to the treating provider, except to the extent that action has been taken in reliance on this authorization.

Patient Attestation

I attest that the information provided on this form is accurate to the best of my knowledge. I have had the opportunity to ask questions about the recommended supplement(s), associated risks and benefits, and available alternatives. I voluntarily consent to the proposed plan as indicated by my signature below.

Sign Now