Patient Disclosure and Consent Form

PATIENT DISCLOSURE AND CONSENT FORM

Patient Name:   Date of Birth:

RECITALS

WHEREAS, the Patient desires to receive medical evaluation, diagnosis, treatment and related services from the Provider; and

WHEREAS, the Provider has explained the nature and purpose of the proposed care, the reasonably foreseeable risks and benefits, alternatives including no treatment, and the anticipated financial responsibilities of the Patient;

NOW, THEREFORE, the Patient acknowledges and consents as set forth in this Patient Disclosure and Consent Form.

SCOPE OF TREATMENT

PAYMENT TERMS AND FINANCIAL RESPONSIBILITY

Estimated Fee for Services: $   Deposit Required: $

Payment Schedule:

Late Payment Penalty: A late fee of will be applied to outstanding balances and collection costs may be charged if account is referred to an outside agency.

Insurance Assignment/Authorization: I authorize the Provider to submit claims and assign benefits to the Provider when applicable. I understand that I am ultimately responsible for all charges not paid or reimbursed by insurance.

CONFIDENTIALITY AND RELEASE OF INFORMATION

The Provider will maintain the confidentiality of Patient records in accordance with applicable law. The Patient authorizes the Provider to disclose protected health information to the following persons or entities for purposes of treatment, payment, or healthcare operations:

The Patient understands that certain disclosures may be required by law (for example, reporting communicable diseases, abuse, or court orders). Except as required by law or these exceptions, the Provider will not disclose protected health information without separate written authorization.

CONSENT TO TREATMENT

I consent to such examinations and procedures as may be considered necessary or advisable by the Provider. I acknowledge that no guarantee has been made as to the results of any treatment. I understand the reasonably foreseeable risks, benefits, and alternatives, and have had the opportunity to ask questions.

RISKS, ALTERNATIVES, AND REFUSAL

The Patient acknowledges that risks, side effects, and complications are possible. Reasonable alternatives, including no treatment, have been explained. The Patient has the right to refuse any proposed treatment and to be informed of the likely consequences of refusal.

TERM, REVOCATION, AND TERMINATION

This authorization is effective as of: and will remain in effect until: unless revoked earlier in writing. To revoke this authorization, the Patient must provide written notice to the Provider; revocation will not affect disclosures made prior to receipt of the revocation.

The Provider reserves the right to terminate the patient-provider relationship for cause with reasonable written notice to the Patient, subject to applicable emergency care obligations.

GOVERNING LAW AND OTHER TERMS

This Agreement shall be governed by and construed in accordance with the laws of the state of without regard to conflict of law principles.

Entire Agreement: This form constitutes the entire written agreement and authorization related to the subjects addressed herein and supersedes any prior written authorizations. Any amendment must be in writing signed by the Patient or authorized representative and an authorized representative of the Provider.

ACKNOWLEDGMENTS

I acknowledge that I have read and understand this Patient Disclosure and Consent Form. I have had the opportunity to ask questions and receive answers. I understand my financial responsibilities and consent to the disclosures and treatments described above where I have indicated consent.

ADDITIONAL NOTES / INSTRUCTIONS

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