LIFE MEDICAL,PA

Initial Consent Form

Patient's Name(First ,Last)
DOB
Email

No changes can be made to the consent of this form or it will be considered invalid Life Medical PA would be unable to treat you. Thank you for your cooperation.

Authorization of treatment of self/minor

By signing this form, I consent to and authorize Life Medical PA, to examine and provide care to myself or the above-named patient/minor. This would include immunization procedures,labs, and allergy treatments as is necessary. I authorize life medical providers to utilize its business associates medically necessary in providing best possible care to me and to share my information with them on the need to know basis bound by HIPPA confidentiality clauses

I also authorize life Medical PA to act on my behalf in case the minor experience a reaction to the authorized treatment or is a victim of injury or illness if immediate medical or surgical is needed, provided diligent effort is made to notify me of the situation and obtain my preferences. If such efforts to contact me are unsuccessful I authorize the above named person to take such action and give such consent on the minor's behalf as the persons reasonable judgement dictates.

I understand that this consent will last for one year unless I change my mind and withdraw by consent sooner in writing. If I withdraw consent it will not affect actions already taken by LIFE MEDICAL,PA.

YESNO

Authorization For Release Of Medical Information For Medical Care

I authorize of release of pertinent medical information to the treating healthcare providers ,for purpose of my medical care and for business operations and to have access to my external medical records via carequality and commonwell.

YESNO

Authorization For Release Of Research Or Quality Improvement

Minnesota law requires us to inform you that your medical records,no matter when created may be released to outside groups for quality improvement purposes unless you object. I authorize this release and agree I may revoke this agreement at anytime in writing delivered to the clinic.I may also inquire about whether such a release has been requested

YESNO

Patient's Right To Privacy

I acknowledge that I am able to obtain a copy of life medical ,PA privacy practices

YESNO

Authorization for Release Of Medical Information For Billing Purposes

I authorize release of pertinent medical information to third party payers /insurance companies to determine payment related to medical treatment received.

YESNO

Authorization Of Medical Information To Someone Other Than Yourself

YESNO

Name of person(s) able to pick up discuss your personal information *

Assignment Of Benefits

I authorize payment of benefits be made directly to Life Medical PA for services provided tomyself or the above named patient. I understand and agree that I am financially responsible for charges not covered by insurance with 90 days after receiving a statemen or otherwise expressely agreed.In the event of default,I agree to pay all costs of collection including reasonable attorny fees.I hereby authorize life medical PA toinvestigate any information obtained from me pertaining to my financial responsibility.

YESNO

If No You are assuming all financial responsibility for your service

Patient's Name
Date *
Relationship to above named minor *