Self Assessment
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GENERAL CONSENT FOR TREATMENT
GENERAL CONSENT FOR TREATMENT
Patient Name:
File Number:
DoB:
Mobile:
Gender:
Next of Kin:
Phone No:
1. I
here by consent professionals to render all medical care to myself or to my dependent, including Physical examination,and other procedures as necessary or advisable in the judgement of center’s physicians and health professionals. I have not been given any guarantees to the results of the services I will receive.
2. Access to Medical Records: I hereby consent that relevant Clinic staff may access my personal medical records for processing insurance claims, quality reviews, medico-legal auditing purposes or as directed by the Hospital Director. I hereby consent that thisdf Ayurvedic Clinic may release my medical records at the request of the Police, Court, Department of Health , and my insurance company/payer. This is applicable while I remain a member of the insurance company will obtain my consent for this purpose. I understand that all personal accessing my records will maintain a professional standard of confidentiality and that will not jeopardize my right to high quality medical care in the future.
I also give consent for my information to be shared with other Government Authorities in the case of Customer product related injuries and /or work-related injuries.
3. Consent for Release of Medical Information to insurance companies/ payer: I, the undersigned, do hereby authorize my Insurance Company/ Payer to have access to and take copies of all my files and records at any time relating to any health care services provided to me during the period of my insurance coverage. I understand from time to time my insurance company/payer may need to disclose information related to my medical files and record to third parties for reasons related to insurance including but not limited to the processing of my claim, research/statistical purposes or to prevent / control fraudulent or improper claims. My insurance company / payer will ensure the confidentiality of all information it receives in relation to this Consent as required by the UAE Law.
4. I am aware that all my medical information (Medical reports, radiology and Laboratory investigation reports, procedural images, discharge summary etc.) will be communicated to me through the email ID provided by me and I hereby authorize this Clinic to release the information in the Email ID provided.
5. Transfer: I agree, I / my dependent’s medical conditions require transferring me/ my dependents from the center,when required
6. Cost Payment: I have been made aware of estimated cost of the treatment by the center. I accept the final cost as my responsibility, when presented at the end of the treatment I agree to pay this cost in full to the center
7. I have been made aware of the Center’s Patient Rights and Responsibilities.
8. I am aware that my investigation test result status, appointments schedule status and promotional message will be communicated through the registered mobile number as text message.
This Consent is valid as long as I am receiving treatment and care at this Ayurvedic Clinic .
Patient/Gurdian Signature
Date :
WITNESS
I, Employee who is not a patient’s physician or authorized health care provider and have witnessed the patient or his/her Substitute Consent giver voluntarily sign this form.
Staff ID Number
Signature
Date :
Patient Signature
Witness Signature
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