Healthcare Technical Procedure

HEALTHCARE TECHNICAL PROCEDURE AUTHORIZATION

Patient Name:    Date of Birth:    Medical Record/ID:

Patient Information

Male    Female    Other:

Insurance Information

Medical History

Contrast / IV dye allergy: Yes    No    Pregnancy status: Yes No Unknown

Procedure Technical Details

Modality / Technical Method:    Estimated Duration:

Location / Body Site:

Local    Conscious Sedation    General Anesthesia    Other:

Risks, Benefits, and Alternatives

The clinician has explained the nature and purpose of the technical procedure, including the expected benefits and the reasonably foreseeable risks. Typical risks may include, but are not limited to, bleeding, infection, radiation exposure, damage to adjacent structures, allergic reaction to contrast or medications, need for conversion to an alternate technique, need for additional procedures, and unforeseen complications that may result in prolonged hospitalization or death. I acknowledge that all significant risks have been discussed with me.

Alternatives to the proposed procedure, including no procedure, less invasive options, or alternative technical approaches, have been presented and discussed. I have had the opportunity to ask questions about alternatives and understand the relative risks and benefits of each.

I understand that during the procedure unforeseen conditions may arise that necessitate additional or different technical steps than those initially planned, and I authorize the clinician to perform such additional procedures as are necessary for my health and safety.

I understand that I may withdraw consent at any time prior to the initiation of the procedure; however, once sedation or anesthesia has begun, withdrawal may not be practical without increasing risk.

Patient Initials:

HIPAA Authorization & Release

By signing below I authorize the release of protected health information related to this procedure to other health care providers and insurers as necessary for treatment, payment, and health care operations. I acknowledge receipt of the facility's privacy practices and understand my rights regarding protected health information.

This authorization for release of information shall expire on:

I authorize and direct any physician, hospital, clinic, or insurer to furnish copies of my medical records and technical images to the performing clinician and to facilities providing follow-up care necessary for my treatment. I understand that information disclosed pursuant to this authorization may include information relating to communicable diseases, behavioral health, and substance use, unless I have specifically indicated restrictions below.

Restrict disclosure of the following sensitive information (if any):

Acknowledgment of Privacy Practices: I acknowledge receipt of the privacy practices notice.

Patient Acknowledgment

I certify that I have read (or had read to me) and understand the information in this authorization and consent. All questions about the nature and purpose of the procedure, the potential benefits, risks and alternatives, and the anesthesia plan have been answered to my satisfaction. I voluntarily request and authorize the technical procedure(s) described above.

Interpreter / Language assistance required: No    Yes    If yes, language:

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