Healthcare Waiver Form

HEALTHCARE WAIVER FORM

Patient Name:    Date of Birth:

Contact & Emergency Information

Insurance Information

Medical History

Current Medications:

Allergies (medications, food, environmental):

Acknowledgment of Risk and Waiver of Liability

I, the undersigned Patient, acknowledge that I have been advised of the nature, purpose, and potential risks associated with the medical services, procedures, tests, or treatments to be provided by the Provider. I understand that all medical procedures carry inherent risks including, without limitation, adverse reactions, complications, infection, worsening of condition, or death.

Assumption of Risk: I knowingly and voluntarily assume all risks associated with the proposed care. I understand that the Provider has explained the expected benefits, material risks, and reasonable alternatives, including the option of no treatment.

Release and Waiver: In consideration of the provision of services, I hereby release, waive, discharge, and covenant not to sue the Provider, its employees, contractors, agents, successors, and assigns from any and all liability, claims, demands, actions or causes of action arising out of or relating to any loss, damage, or injury, including death, that may be sustained by me as a result of the services, except for acts of gross negligence or intentional misconduct.

Indemnification: I agree to indemnify and hold harmless the Provider against any claims, liabilities, losses, costs, or expenses (including reasonable attorneys’ fees) arising from my negligent or intentional acts or omissions in connection with the services provided.

Emergency Treatment Authorization: If, in the opinion of medical personnel, emergency treatment is necessary and I am unable to provide consent, I authorize the Provider and its staff to provide such emergency care as may be necessary for my well-being. I understand I am responsible for costs of emergency care.

Privacy, Information Release, and HIPAA Acknowledgment

Authorization to Use and Disclose Health Information: I authorize the Provider to use and disclose my protected health information for treatment, payment, and healthcare operations as reasonably necessary. I authorize release of information to my insurance carrier and other providers involved in my care. I understand that this authorization may be revoked in writing at any time, except to the extent that action has already been taken in reliance upon it.

I acknowledge that I have received and read the Provider's privacy practices and that I understand my rights regarding protected health information.

Consent, Withdrawal, and Authorization Expiration

Voluntary Consent: I certify that I voluntarily consent to the proposed care and that all information provided on this form is true and accurate to the best of my knowledge. I understand I may ask questions about the recommended procedures and the associated risks and benefits prior to giving consent.

Right to Withdraw: I understand that I may withdraw this consent at any time by providing written notice to the Provider. Withdrawal will not affect actions already taken in reliance on this consent prior to receipt of the notice of withdrawal.

Additional Acknowledgements

COVID-19 and Communicable Disease: I acknowledge that there are risks associated with receiving care during an outbreak of communicable disease and that the Provider has instituted infection control measures. I accept those risks and agree to follow facility instructions regarding screening, masking, and testing where applicable.

Certification: I certify under penalty of perjury that I am the person named above or that I am authorized to sign on behalf of the patient named above. I have read and understand this waiver and consent in its entirety, and I agree that this document is binding and enforceable.

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