Healthcare W&I Document

HEALTHCARE WAIVER AND INDEMNITY (W&I) AGREEMENT

Patient Information

Date of Birth:    Gender:

Phone:    Email:

Relationship:    Phone:

Insurance Information

Policy/ID Number:    Group Number:

Medical History

Procedure / Service Description

Procedure or Service to be Provided:

I acknowledge that the described procedure or service has been explained to me, including the anticipated benefits, reasonably foreseeable risks, complications, and alternative treatment options. I understand that no guarantee or assurance has been given by anyone regarding the results of the procedure.

Waiver, Release and Indemnity

In consideration of receiving medical treatment, I, the undersigned patient (or the patient's lawful representative), hereby voluntarily waive, release, and discharge the healthcare provider, its physicians, nurses, employees, agents, and affiliated entities (collectively, the Provider) from any and all claims, liabilities, causes of action, damages, or demands arising out of or related to the provision of the described treatment, to the maximum extent permitted by law. This waiver and release includes claims based on negligence but does not include claims arising from the Provider's gross negligence, willful misconduct, or acts that cannot be waived by applicable law.

I agree to indemnify, defend, and hold harmless the Provider from and against any and all third-party claims, demands, causes of action, losses, liabilities, costs, and expenses (including reasonable attorneys' fees) arising out of my actions, failure to disclose material medical information, or breaches of this Agreement. This indemnity obligation shall survive completion of treatment and the termination of this Agreement.

If the treatment is compensable under workers' compensation, automobile insurance, or other third-party payor, I agree to notify the Provider promptly. I authorize the Provider to pursue reimbursement from responsible third parties and acknowledge that this Waiver and Indemnity may impact recovery rights as permitted by law.

HIPAA Privacy and Authorization to Release Information

I acknowledge receipt of the Provider's Notice of Privacy Practices and understand my rights regarding protected health information. I authorize the Provider to use and disclose my protected health information for purposes of treatment, payment, and healthcare operations and to release such information to insurers, other healthcare providers, and as required by law for the purpose of payment and coordination of care.

This authorization includes release of records related to mental health treatment, communicable diseases, and substance use disorder treatment, to the extent permitted by law, unless I have expressly indicated otherwise below.

Authorization Expiration Date:

Acknowledgments and Certifications

  I acknowledge that I have been informed of the risks, benefits, and alternatives to the proposed treatment and that I have had an opportunity to ask questions which have been answered to my satisfaction.

  I certify that the information I have provided on this form is true and complete to the best of my knowledge and that I will inform the Provider of any changes in my medical condition or insurance status.

  I acknowledge receipt of the Provider's Privacy Practices and authorize the use and disclosure of my protected health information as described above.

Workers' Compensation / Third-Party Information

Is this treatment related to an occupational injury, motor vehicle accident, or third-party claim? Occupational Injury Motor Vehicle Other Third Party

Patient Certification of Capacity

By signing below I certify that I am at least 18 years of age and legally competent to execute this Waiver and Indemnity Agreement. If the signatory is a legal guardian, parent, or authorized representative, the signatory certifies authority to execute this Agreement on behalf of the patient and must provide a description of the legal relationship.

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