Healthcare Waiver and Release Form

HEALTHCARE WAIVER AND RELEASE FORM

Patient Information

Date of Birth:    Gender:

Relationship:    Phone:

Insurance Information

Medical History (summary)

Description of Procedure or Treatment

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

Anticipated Date of Procedure:

Risks, Benefits, and Alternatives

I acknowledge that the nature, purpose, risks, benefits, and reasonable alternatives to the proposed procedure have been explained to me in terms I understand. Known risks may include, but are not limited to, infection, bleeding, scarring, allergic reaction, and unanticipated complications. Alternatives, including no treatment, have been discussed.

I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction.

I acknowledge that I understand the risks, benefits, and alternatives described above.

I have had the opportunity to ask questions and have received satisfactory answers.

Waiver, Release and Indemnification

In consideration of receiving the foregoing medical services, I hereby release, waive, discharge and covenant not to sue Provider, its agents, employees, contractors, affiliates, successors and assigns (collectively "Released Parties") for any and all liability, claims, demands, actions or causes of action arising out of or related to any loss, damage, illness or injury that may be sustained by me or my property, whether caused by the negligence of the Released Parties or otherwise, to the fullest extent permitted by law.

I further agree to indemnify, defend and hold harmless the Released Parties from and against any and all claims, costs, losses and damages, including attorneys' fees, arising out of or related to my acts, omissions, or breaches of this agreement.

I understand that nothing in this Waiver and Release is intended to release claims that cannot be released as a matter of law, including claims for gross negligence or intentional misconduct where such release is prohibited.

HIPAA Authorization and Privacy

I authorize Provider to use and disclose my protected health information for purposes of treatment, payment, and healthcare operations as necessary to provide the services described above. I understand that this authorization permits release to individuals I designate below and that I may revoke this authorization in writing except to the extent that action has been taken in reliance on it.

Authorization Expiration Date:

I consent to the release of my medical records to the individuals named above and to other parties as required for treatment, payment, or as authorized by law.

Emergency Treatment Consent

If an emergency arises and I am unable to give consent, I authorize Provider and its designees to provide such emergency care as deemed necessary to protect my life or health. I understand that I may be responsible for the costs of such emergency care.

I authorize emergency treatment as described above.

Voluntary Signature and Certification

I certify that I am the patient, or that I am legally authorized to sign on behalf of the patient. By signing below I indicate that I have read and understand this Healthcare Waiver and Release Form, that all information I have provided is true and correct to the best of my knowledge, and that I enter into this agreement voluntarily.

I certify under penalty of perjury that the foregoing is true and correct.

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