Medical Consent Form (US) by OLL
A comprehensive medical intake and consent form for patients at US health centers or outpatient clinics. It combines general consent to treatment, optional procedure-specific informed consent, acknowledgement of privacy practices, and financial responsibility into a single signing.
MEDICAL CONSENT FORM (US)
Note: This form collects, in one signing, the consents a clinic or community health center needs before it treats a new patient: general consent to care, an optional consent to a named procedure, acknowledgment of the privacy notice, financial responsibility, contact permissions, language assistance, and a signature block for a parent or other representative. Complete every yellow field and complete Exhibit A. Where a section offers Option A or Option B, keep one and delete the other.
Note: Two things stay out of this form on purpose. First, a HIPAA authorization to release records to a third party (an employer, a lawyer, a relative) must be a separate document: federal privacy rules prohibit combining an authorization with any other document and prohibit making treatment depend on signing one (45 C.F.R. 164.508). Second, a procedure-specific informed consent discussion is governed by the law of your state. Section 2 gives you a form for it, but the conversation with the practitioner is what the law requires, not the signature alone.
This Medical Consent Form (this "Consent") is given on [date of consent] by [full name of the patient], date of birth [date of birth of the patient] (the "Patient"), or by the Patient's representative named in Section 10, to [legal name of the health center] of [address of the health center], telephone [telephone number of the health center] (the "Health Center"). Where this Consent says "I" or "me", it means the Patient, or the representative signing for the Patient.
Note: Use "Health Center" for any clinic, medical practice, community health center, or other outpatient provider. The form is written for outpatient care. A hospital admission uses the hospital's own conditions of admission, which carry additional federal requirements.
1. CONSENT TO TREATMENT
1.1 General consent. I consent to examination, diagnosis, treatment, and routine care at the Health Center by its physicians, nurse practitioners, physician assistants, nurses, behavioral health practitioners, dental practitioners, and other licensed staff, and by students and trainees working under their supervision. Routine care includes taking a medical history, physical examination, vital signs, laboratory tests, imaging, vaccinations, prescribing and administering medication, and minor office procedures.
1.2 What this consent does not cover. This general consent does not cover surgery, anesthesia or sedation, invasive procedures, or any treatment that the Health Center's policies or the law of the state in which I am treated require to have its own written consent. For those, I will be asked to sign Section 2 of this form or a separate consent after the practitioner has explained the procedure to me.
1.3 No guarantee. I understand that medicine is not an exact science and that no one has promised me a particular result.
1.4 My questions. I have had the chance to ask questions about my care and to have them answered in a way I understand.
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