Healthcare Unsigned Document

Healthcare Unsigned Document

This document contains a combined clinical consent, authorization for release of protected health information, and acknowledgments required prior to treatment. Completing and signing this form grants the health care provider the authority described below and acknowledges receipt of the provider's privacy practices. This form is unsigned and remains invalid until signed by the patient or the patient's legally authorized representative.

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance Information

Medical History

Consent for Treatment

I authorize the provider, its physicians, nurses and other authorized personnel to provide medical care, diagnostic testing, and treatment as deemed necessary or advisable by the provider. This authorization includes routine procedures, examinations, administration of medications, and such additional procedures as may be required in the exercise of professional judgment.

The provider has explained the nature and purpose of the proposed treatment, anticipated benefits, frequently encountered risks and complications, and reasonably available alternatives, including the option of no treatment. I understand that medicine and surgery are not exact sciences and that no guarantees have been made regarding the outcome of the proposed treatment.

I consent to the proposed treatment and related care as described above.
I decline the proposed treatment at this time.

Risks, Benefits and Alternatives

Potential risks and complications have been explained and may include, but are not limited to, infection, bleeding, allergic reaction, adverse drug interaction, scarring, continued symptoms, need for further treatment, or unforeseen complications. I have had an opportunity to ask questions and understand that not all potential risks can be listed.

I acknowledge that the risks, benefits, and alternatives have been explained to me in terms I understand.

Authorization for Release of Protected Health Information (PHI)

I authorize the release of my medical information, including diagnostic reports, treatment records, and billing information, to the persons and organizations involved in my care, to my insurance carrier for payment and coverage determination, and to other parties only as permitted by law or as I specifically direct in writing below.

Expiration of Authorization:

I authorize release of PHI as described above. I understand that I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance on it.

Financial Responsibility and Assignment

I accept financial responsibility for services rendered and authorize my insurer to pay benefits directly to the provider where applicable. I understand that I am responsible for charges not covered by my insurer, including co-payments, deductibles, and non-covered services.

I accept financial responsibility and assign benefits where applicable.

Privacy Practices Acknowledgment

I acknowledge that I have been offered or provided with the provider's Notice of Privacy Practices describing how my health information may be used and disclosed and my rights under applicable privacy laws.

I acknowledge receipt of the Notice of Privacy Practices.
I decline to acknowledge receipt at this time.

Right to Withdraw Consent / Revocation

I understand that I may revoke any portion of this authorization in writing at any time, except to the extent that action has already been taken in reliance on the authorization. Revocation should be submitted in writing to the provider's medical records department or the clinic administrator.

Patient Certification

By signing below I certify that I am the patient or the legally authorized representative of the patient and that I have read and understand the information contained in this document. I have had the opportunity to ask questions and those questions have been answered to my satisfaction. I acknowledge that signing this form constitutes informed consent for treatment and authorization as indicated above.

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