Healthcare Treatment Agreement

HEALTHCARE TREATMENT AGREEMENT

PARTIES AND EFFECTIVE DATE

This Healthcare Treatment Agreement ("Agreement") is entered into by and between Patient and Provider on the Effective Date. Patient Name: and Provider Name: .

Effective Date:

PATIENT INFORMATION

Female    Male    Other / Non-binary   

INSURANCE AND FINANCIAL RESPONSIBILITY

I understand that I am financially responsible for services rendered that are not covered or paid by my insurer. If the Provider is authorized to bill my insurer, I hereby assign benefits and authorize payment directly to the Provider. I agree to pay any copayment, deductible, coinsurance, or noncovered services. Patient responsible for estimated cost:

MEDICAL HISTORY

DESCRIPTION OF PROPOSED TREATMENT

Provider will perform the following treatment or procedure(s):

RISKS, BENEFITS AND ALTERNATIVES

Provider has explained the nature and purpose of the proposed treatment, the anticipated benefits, material risks, and reasonably available alternatives including the option of no treatment. Material risks may include, but are not limited to, infection, bleeding, adverse reaction to medication, scarring, incomplete resolution of the condition, and unforeseen complications. Alternatives explained:

I acknowledge that no guarantee has been made as to the results of the proposed treatment and that unforeseen circumstances may require additional procedures or modification of the procedure. I have been given the opportunity to ask questions and all my questions have been answered to my satisfaction.

Patient initials to confirm understanding of risks and alternatives:

CONSENT AND AUTHORIZATION

By signing this Agreement, I authorize the Provider and staff to perform the treatment described above and any ancillary services necessary for my care, including administration of medications, diagnostic testing, and emergency care. I consent to such treatment and understand that I may withdraw this consent at any time prior to a procedure or treatment by notifying Provider in writing, except where action has already been taken in reliance on this consent.

RELEASE OF RECORDS / AUTHORIZATION FOR USE AND DISCLOSURE

I authorize the Provider to release medical information required for my care, billing, or as otherwise permitted or required by law. I authorize release of information to my insurance company, referring physician, and other healthcare providers involved in my care unless I have specifically restricted such release in writing.

HIPAA Authorization Expiration Date: . If no date is entered, this authorization will expire one year from the Effective Date.

I authorize the Provider to obtain and release my protected health information as necessary for treatment, payment, and healthcare operations. I understand that I may revoke this authorization in writing except where the Provider has already acted in reliance on it.

EMERGENCY TREATMENT

In the event of an emergency, I authorize the Provider to take such measures as are, in the Provider's judgment, necessary for my immediate care and safety, including hospital transfer and emergency medical interventions.

MINORS AND GUARDIANS

If the patient is a minor or otherwise unable to consent, the person signing below represents that they are the parent, legal guardian, or authorized representative and have the legal authority to consent to treatment on behalf of the patient. Guardian/Representative Name: Relationship to Patient:

MISCELLANEOUS TERMS

This Agreement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior discussions and agreements. If any provision of this Agreement is held invalid, the remainder shall continue in full force and effect. This Agreement shall be governed by the laws of the jurisdiction in which the Provider maintains the primary practice location.

ACKNOWLEDGMENT

By signing below, I certify that I have read and understand this Agreement, that the nature and purpose of the proposed treatment(s) and the risks and alternatives have been explained to me, and that I consent to the treatment described above.

If signed by a representative, indicate capacity and authority to sign on behalf of the patient (e.g., parent, legal guardian, healthcare proxy):

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