Healthcare Surgeon Support Form

Healthcare Surgeon Support Form

Use this form to document requested intraoperative and perioperative support for the listed patient and to obtain the patient's authorization for disclosure of relevant medical information to the surgical support team. Completion of this form provides clinical, logistical, and consent information required for operative planning and support allocation.

Patient Information

Date of Birth:    Medical Record Number:

Male Female Other Specify:

Insurance Information

Surgeon & Procedure Details

CPT Code (if known):    Scheduled Procedure Date:    Scheduled Start Time:

Estimated Procedure Duration:    Urgency: Elective Urgent Emergency

Requested Support Services

Please indicate required intraoperative support (check all that apply):

First Assist (Physician Assistant / RNFA) Surgical Assistant (resident/fellow) Dedicated Anesthesia Support Additional Circulator Additional Scrub Technician Intraoperative Imaging (specify below) Cell-saver Required Blood Products Anticipated (specify below)

Medical History & Allergies

Pregnancy status: Positive Negative / Not applicable    DNR / Advanced Directives on file: Yes No

Perioperative Orders & Precautions

NPO Since (time/date):    Additional Precautions / Notes:

Authorization, Consent, and Acknowledgements

I, the undersigned patient or legally authorized representative, authorize the primary surgeon, surgical assistants, anesthesia providers, nursing staff, and other personnel reasonably necessary to perform the procedure and related perioperative care. I authorize release of necessary medical information to personnel and departments involved in the provision of surgical support and to my insurer for purposes of coverage and payment.

I understand that the use of assisting personnel, implants, blood products, and specialized equipment carries specific risks, including but not limited to bleeding, infection, reaction to transfused blood, device failure, and the need for unanticipated additional procedures. I have had the opportunity to ask questions about the planned support and the nature of the risks and benefits, and my questions have been answered to my satisfaction.

I understand that I may withdraw this authorization at any time prior to the procedure by notifying the surgical team, except to the extent that action has already been taken in reliance upon it. I acknowledge that withdrawing consent may result in postponement or cancellation of the procedure if agreed support services cannot be provided otherwise.

I acknowledge receipt of the facility's Notice of Privacy Practices and consent to disclosure of protected health information to the surgical support team as necessary for treatment, payment, and healthcare operations.

Authorization Expiration Date:

Patient Financial Responsibility: I acknowledge that I am financially responsible for charges not paid by my insurer, including services provided by independent practitioners or third-party suppliers arranged to support the procedure, unless otherwise covered by contract.

Additional Notes / Clinical Instructions

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