Healthcare Surgical Contract

HEALTHCARE SURGICAL CONTRACT

Parties and Agreement

This Surgical Contract (the "Contract") is entered into by and between Patient Name: and Medical Provider/Facility Name: . The parties agree as follows.

Patient Information

Emergency Contact

Insurance and Financial Responsibility

Patient acknowledges financial responsibility for deductibles, co-payments, non-covered services and any balance not reimbursed by insurance. Patient agrees that Medical Provider may bill patient and/or any responsible third party for services rendered and that patient will be responsible for payment if claims are denied or unpaid.

Procedure Details and Authorization

I authorize the Medical Provider and such assistants and consultants as may be selected to perform the procedure described above, and to administer such anesthesia and other medications as deemed necessary. I understand that the practice of medicine and surgery is not an exact science and acknowledge that no guarantees have been made concerning the results of the procedure.

Anesthesia, Blood Products and Related Treatment

I consent to the administration of general, regional or local anesthesia as indicated. I authorize administration of blood or blood products if deemed medically necessary; however I understand risks and alternatives and have indicated the following regarding blood products:

Risks, Benefits and Alternatives

The Medical Provider has explained to me, in terms I understand, the nature of the proposed procedure, the expected benefits, the significant risks (including but not limited to infection, bleeding, nerve injury, scarring, anesthesia risks, complications requiring additional procedures, and death) and reasonable alternatives including non-operative management. I acknowledge that complications may occur despite appropriate care.

Medical History and Current Condition

Consent for Photography and Records

I authorize the taking of clinical photographs, video or other images for documentation, diagnosis, treatment or education. I understand such images will be part of my medical record and may be used for teaching or publication if de-identified, unless I object below.

HIPAA Authorization and Privacy Acknowledgment

I acknowledge receipt of the provider's Notice of Privacy Practices and authorize use and disclosure of my protected health information for treatment, payment and health care operations. I authorize the release of medical information to my insurer, referring physician, and other providers as necessary for care and billing.

Cancellations, No-Show and Additional Costs

Patient understands scheduling policies and may be charged for late cancellations or no-shows. Patient agrees to pay for additional services, supplies or procedures not covered by insurance that are necessary at the time of surgery.

Limitations on Liability and Arbitration

Except to the extent prohibited by law, patient and provider agree that claims arising from this Contract will be resolved under the dispute resolution provisions set forth by the provider. Patient acknowledges understanding that claims for malpractice or negligence are subject to applicable statutes and that this Contract does not eliminate any rights granted by law.

Patient Representations and Acknowledgments

I represent that I have provided a full and accurate medical history to the best of my knowledge, including medications, allergies, prior procedures, and chronic conditions. I have had the opportunity to ask questions and those questions have been answered in a manner I understand. I understand I may withdraw consent at any time prior to initiation of anesthesia or the procedure.

Special Instructions / Patient Notes

Emergency Treatment Authorization: If an emergency arises during the provision of care, and I am unable to give consent, I authorize the Medical Provider to take such actions as are medically appropriate including transfer to a hospital or the use of emergency procedures.

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