Healthcare UI Treatment Form

HEALTHCARE UI TREATMENT FORM

Patient Information

Date of Birth:    Gender: Male Female Other

Insurance Information

Clinical Assessment: Urinary Incontinence (UI)

Symptom onset (approx.):    Frequency: Daily Weekly Occasional

UI Type (check all that apply): Stress Urge Mixed Overflow Other:

Medical History

Proposed Treatment Plan

Estimated number of treatment sessions or duration:

Risks, Benefits and Alternatives

I acknowledge that the provider has explained the nature of the proposed UI treatments, expected benefits, material risks, and reasonable alternatives. Common and serious risks discussed include infection, bleeding, urinary retention, worsening symptoms, transient or persistent pain, device-related complications, need for repeat treatment, and anesthetic or medication reactions. No guarantee of cure or complete symptom resolution has been made.

I have been offered the following alternatives (check those discussed): Behavioral therapy / bladder training Pelvic floor physical therapy Medication management Surgical options Observation

Consent to Treatment

By signing below I consent to the above treatment plan and any ancillary care reasonably required in relation to these treatments. I authorize the clinical team to perform examinations, administer medications, obtain diagnostic tests, and provide treatment as indicated. I understand I may revoke this consent at any time in writing, except to the extent that actions have already been taken in reliance on this consent.

I certify that I have had the opportunity to ask questions about the nature, purpose, risks, benefits and alternatives of the proposed treatments and that my questions have been answered to my satisfaction.

Authorization for Release of Health Information (HIPAA)

I authorize the release of my protected health information related to evaluation and treatment of urinary incontinence to the following individuals or entities for the purposes stated below:

This authorization will expire on: or upon written revocation submitted to the provider. I understand that revocation will not affect disclosures made prior to receipt of the revocation.

I understand that information disclosed pursuant to this authorization may be re-disclosed by the recipient and may no longer be protected by federal privacy regulations. I release the provider and its agents from liability that may arise from this authorized release of information, except as prohibited by law.

Financial Responsibility & Acknowledgment

I acknowledge financial responsibility for services not covered or paid by my insurer, including co-payments, co-insurance, deductibles, and services deemed not medically necessary. I authorize payment of benefits to the provider for services rendered.

I certify that the information I have provided on this form is true and complete to the best of my knowledge and that I will notify the clinic of any changes to my health status or insurance coverage.

Acknowledgements

I acknowledge receipt of the clinic's privacy practices and understand my rights regarding my protected health information.

I have had the opportunity to ask questions and have received answers that I understand regarding my condition and proposed treatment.

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