Healthcare Waiver Grant

HEALTHCARE WAIVER GRANT

This Healthcare Waiver Grant documents the voluntary grant of limited waivers, authorizations, and assumptions of risk by the undersigned patient or legally authorized representative to the Provider identified below. Patient Name: Date of Birth: Patient ID/Account #:

Patient Information

Female Male Other/Prefer not to disclose

Insurance & Financial Responsibility

Medical History (relevant to this waiver)

Scope of Waiver Grant

The undersigned hereby grants the Provider and its agents the following limited waivers and authorizations as indicated below. These waivers are effective only for the purposes and duration expressly stated herein.

I consent to the treatment, diagnostic procedures, and ancillary care described in the Procedure/Treatment Description below, and waive any claim of lack of informed consent to the extent described in this document.

I authorize limited disclosure of my protected health information (PHI) to the persons named in the HIPAA Authorization section for the purposes indicated.

I accept financial responsibility for charges not paid by insurance and waive any right to contest collection for amounts properly owed under applicable law, except where prohibited by statute.

Procedure / Service Description

Risks, Benefits, and Alternatives

The Provider has explained to me the nature, expected benefits, material risks, and reasonable alternatives to the proposed procedure or service. I understand that all medical and surgical procedures involve inherent risks and that outcomes cannot be guaranteed. I acknowledge that I have had the opportunity to ask questions and that those questions have been answered to my satisfaction.

Check to acknowledge that risks, benefits, and alternatives were discussed:

HIPAA / Privacy Authorization

I authorize the Provider to disclose the minimum necessary protected health information to the following person(s) or entity(ies) for the purpose(s) indicated. This authorization is voluntary and may be revoked in writing except to the extent action has already been taken in reliance thereon.

Purpose(s) of disclosure: Continuity of care Billing/Insurance Personal representative

Certification and Waiver of Liability

By signing this document I certify that I am the patient or the legally authorized representative of the patient with authority to execute this Healthcare Waiver Grant. To the fullest extent permitted by law, I hereby release and waive any claims, causes of action, or demands against the Provider and its officers, employees, contractors and agents arising from or related to the provision of the services described above, except for claims arising from gross negligence, willful misconduct, or other actions that the law does not permit to be waived. This waiver does not apply to statutory rights that are non-waivable.

I acknowledge that I retain the right to revoke this authorization in writing at any time except to the extent that action has already been taken in reliance on it. Revocation must be submitted in writing to the Provider and will not affect disclosures made prior to receipt of the revocation.

Acknowledgments

Interpreter required: Yes No

If patient is a minor or otherwise unable to sign, this form must be signed by a parent or legal guardian. Relationship to patient (if signing as guardian):

I certify under penalty of perjury under applicable law that the information provided on this form is true and correct and that I have read, understand, and agree to the terms of this Healthcare Waiver Grant.

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