Healthcare W&I Form

HEALTHCARE W&I FORM

Patient Information

Patient Name:

Date of Birth:

Insurance Information

Medical History

Description of Treatment / Procedure

Brief description of proposed treatment or procedure:

Risks, Benefits, and Alternatives

I acknowledge that the physician or provider has explained the nature and purpose of the proposed treatment, the significant risks and potential complications, the expected benefits, and reasonable alternatives including the option of no treatment. I understand that no guarantee has been made as to results.

I have been given the opportunity to ask questions and all questions have been answered to my satisfaction. I understand that complications may include, but are not limited to, infection, bleeding, adverse reaction to medications, scarring, and other consequences inherent to the procedure or treatment described above.

I acknowledge that I have received, read, and understand the information regarding risks, benefits, and alternatives.

Waiver and Indemnity

In consideration of receiving medical services and treatment, I hereby release, waive, and forever discharge the medical provider, affiliated facilities, their employees, agents, contractors, and representatives (collectively the Provider) from any and all claims, demands, causes of action, suits, liabilities, costs and expenses, including attorney fees, arising out of or related to the treatment, except to the extent caused by the Provider's gross negligence or willful misconduct.

I agree to indemnify and hold harmless the Provider from any third-party claims arising from my actions or omissions in connection with the treatment, including claims brought by family members or other persons on my behalf, except to the extent attributable to the Provider's gross negligence or willful misconduct. This indemnity includes costs of defense and reasonable attorney fees.

Voluntary Consent and Right to Withdraw

I affirm that my consent to the proposed treatment or procedure is given voluntarily and without coercion. I understand that I may withdraw this consent at any time prior to the administration of treatment; however, I understand that withdrawal of consent will not affect any actions already taken in reliance on my prior consent and may limit future treatment options.

I understand that if I am unable to make decisions at the time of treatment, the Provider may rely on a previously designated health care agent or legally authorized representative to make decisions consistent with my wishes and best interests.

Privacy, Release and HIPAA Authorization

I authorize the Provider to use and disclose my protected health information for treatment, payment, and health care operations as necessary to administer my care. I further authorize the Provider to disclose relevant health information to my emergency contact and to the following persons for the purpose of discussing my diagnosis and treatment:

This authorization is valid until: unless earlier revoked in writing. I understand that I may revoke this authorization at any time, except to the extent that action has already been taken in reliance upon it.

I acknowledge receipt of the Provider's Notice of Privacy Practices and understand how my health information may be used and disclosed.

Consent Certification

By signing below I certify that I am the patient or the patient's legal guardian or authorized representative, that I am at least 18 years of age unless otherwise indicated, and that I have authority to authorize the treatment and to execute this Waiver and Indemnity. I certify that the information provided on this form is true and correct to the best of my knowledge.

If signing as a guardian or authorized representative, state your relationship to the patient:

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