Healthcare Waiver Application

HEALTHCARE WAIVER APPLICATION

Patient Information

Patient Name:

Date of Birth:   Gender: Male Female Other

Insurance Information

Medical History

Waiver Request Details

Type of Waiver Requested (check all that apply):

Refusal of proposed treatment or procedure
Immunization exemption / refusal
Medication refusal
Request for financial liability waiver or reduction
Other (explain below)

Scheduled Date (if applicable):

Acknowledgment of Risks, Benefits, and Consequences

I acknowledge that my request to waive or refuse the above treatment, procedure, immunization, or medication has been discussed with clinical staff and that reasonable alternatives have been explained. I understand the likely benefits of the recommended treatment and the material risks and possible adverse outcomes of refusing or postponing recommended care, which may include increased morbidity, prolonged recovery, permanent injury, or death.

I understand that by signing this Waiver Application I assume responsibility for any outcomes arising from my decision to refuse or waive the specified care, and I release the facility, its employees, agents, and treating physicians from liability for harm that results from my refusal, except for acts of gross negligence or willful misconduct.

Where a financial liability waiver is requested, this application constitutes a request for review only and does not by itself obligate the facility to grant a waiver. I certify that the financial information I provide is true and complete and authorize the facility to verify information as necessary for financial review.

I understand that I may withdraw this waiver in writing at any time; however, withdrawal will not affect liability for services already provided or actions already taken in reliance on this waiver prior to receipt of written withdrawal.

Privacy and Authorization

I acknowledge that I have been offered the facility's Notice of Privacy Practices and understand that protected health information necessary to evaluate and process this waiver application may be used and disclosed to staff and ancillary personnel involved in my care and in the facility's administrative and financial processes. This acknowledgment does not authorize uses or disclosures beyond those described in the Notice of Privacy Practices.

I authorize the facility to obtain relevant records from other providers as necessary to review this application and to disclose information to third parties solely as necessary to process this request.

Expiration Date:

Certification

I certify that the information provided in this Healthcare Waiver Application is true, correct, and complete to the best of my knowledge. I understand that knowingly providing false information may be subject to civil or criminal penalties. I agree to notify the facility promptly if any information provided herein changes.

By signing below, I attest that I have the authority to make this decision. If signing on behalf of the patient, I certify that I am the patient's parent, legal guardian, or authorized representative and that I will provide documentation of such authority upon request.

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