Consent to Treat Form

Consent for Treatment

I hereby give my consent to my physician and/or his designated healthcare specialist for the evaluation, diagnostics, testing, and treatment. I understand that I may request and receive information on the specific affiliation(s) of any particular healthcare provider I encounter during my care. I give this consent for this treatment session only. 

Consent to Release Information

I understand that protected health information may refer to medical or health information, including prognosis, psychological or mental illness, prescription, laboratory, and other medical results, including HIV tests or diagnosis.

I give my consent for the release of my protected health information for the purpose of treatment, payment, and other relevant health care operations. 

I hereby authorize the medical facility to use my medical information for their exercise of rights, title, and interest in the payment from healthcare insurance services or third-party payors, including but not limited to Medicare, insurance, among others for which are only covered by them.

I understand that there are certain procedures and/or treatments that may not be covered or partially covered by healthcare insurance services. In this case, I understand that I shall be financially responsible and may receive a separate billing for the procedures taken.

Photograph Consent

I hereby give my consent to the taking of my photograph for the purpose of identification for treatment if necessary, or for the purpose of identity for records and/or payment purposes. These photographs shall be kept by the medical facility for the incidental purpose as it may be deemed necessary for the processing of my information.

I hereby declare that I am of legal age and quipped of my mental faculties to give my consent. I have had the opportunity to ask questions and clarifications, and by which I have received answers to my satisfaction.