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Patient Consent Form

The patient consent form summarizes the key points of consent for a medical treatment. It states that the patient has received counseling from their physician about the treatment, understands the treatment may not be FDA approved, and accepts responsibility for payment. The patient acknowledges the physician may use their information for treatment, payment, and operations consistent with HIPAA. The consent will remain valid until revoked in writing.

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waseem iqbal
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457 views1 page

Patient Consent Form

The patient consent form summarizes the key points of consent for a medical treatment. It states that the patient has received counseling from their physician about the treatment, understands the treatment may not be FDA approved, and accepts responsibility for payment. The patient acknowledges the physician may use their information for treatment, payment, and operations consistent with HIPAA. The consent will remain valid until revoked in writing.

Uploaded by

waseem iqbal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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PATIENT CONSENT FORM

PHYSICIAN COUNSELING:
I have received counseling from the physician administering this treatment and am willingto take it as
directed and under the physician’s supervision.

FDA APPROVAL STATUS:


I understand that the treatment I will be receiving may have not been approved by the FDA to treat my condition .

OFF-LABEL AND NO-LABEL USE:


I understand that the prescribing of this medication and my use of it is either an off-label (non-FDA approved) use of this
medication or that the medication does not have an approved use by the FDA. Off-label use of this medicationmeans that the
FDA has not approved the use of thismedicationfor the purposesfor which the doctor has prescribed it to me.

FINANCIAL RESPONSIBILITY:
I understand that I am responsible for all charges for the medication prescribed to me and that the medication will
not be provided to me until payment has been made. I am aware that this is the case not only for the initial
prescription but also for any refills the physician may have prescribed. I understand that I may be contacted by an
agent from my physician’s office or a qualified third party to facilitate payment.

GENERAL PROVISIONS:
I acknowledge that the prescribing physician may use and disclose my information as necessary for the purposes of
treatment, payment, and healthcare operations. This shall be done in a manner consistent with HIPAA regulations and
applicable requirements.

I intend this consent to be continuing in nature and that it will remain in full force until revoked in writing. A

photocopy of this consent shall be considered as valid as the original.

I have read or have had read to me all of the above statements and understand them. I have had the
opportunity to ask any questions I might have about the medication and the treatment being prescribed, any
potential risks, and the alternatives prior to my informed consent. I give consent for this medication/treatment to
be prescribed to me and for my use of it as directed by my physician.

Patient Signature: Date:

Patient Name (please print):

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