Medical/Surgical Treatment Consent Form (18+)

Please read the entire form carefully and complete the information as it applies to you before signing the form. The hospital will not be liable for any act of omission or commission from the release of the patient’s information based on this consent.

NAME AND ADDRESS OF PERSON/ENTITY TO WHOM MY MEDICAL RECORDS WILL BE DISCLOSED

1. Subject to the exceptions in this form, this consent is valid for the release of all medical records from date prior to when this form is signed or as specified below: From: _____/____/____ to ____/____/_____
2. I may revoke this consent at any time by notifying the providing organization in writing and submit it to its address, and it will be effective on the date notified except to the extent action has already been taken in reliance upon it.
3. Unless revoked, this consent will expire on the following date, event or condition ____________________ ______________________________________________________________________________________ If I fail to specify any date, event, or condition, this authorization will expire 60 days from the date signed.
4. I understand that I am not required to sign this consent and that the organization to which this information is released may not condition treatment or coverage on my providing this consent, except as may be permitted by law.
5. I understand that information used or disclosed pursuant to this consent may be redisclosed by the recipient subject to the provisions of existing legislation.

I have read the above authorization and do hereby acknowledge that I fully understand the terms and conditions of this authorization and a copy given to me.