1. I request and authorize medical or surgical treatment as may be deemed necessary and appropriate by the physicians and hi/her designees and assistants participated in my care. This care may include surgical and laboratory procedures; local anesthesia; therapeutic procedures; and medications. I know procedures that have more risk will be explained to me so I can give informed consent for them. I know I can ask my doctor any question(s) I have about my treatment.
2. I authorized Ohio Dermatology Center to release pertinent information and/or copies of medical records for treatment, payment, or health care operations purposes. I understand such information may include human immunodeficiency virus (HIV), AIDS related complex (ARC), acquired immunodeficiency syndrome (AIDS), hepatitis, and substance abuse, if any.
3. I understand and agree that, in accordance with State law, an HIV, HBV, or HCV tests may be performed upon me in the even a health care worker sustains a significant exposure to my blood or bodily fluids. The results of any test will be treated confidentially.
4. I authorize Ohio Dermatology Center to retain, preserve, or use for research, scientific, scientific or teaching purposes, or to dispose of any specimen or tissue remaining after completion of a clinical procedure or treatment.
5. I release Ohio Sermatology Center from responsibility for all personal articles which I have with me during the time I am at Ohio Dermatology Center. I understand that Ohio Dermatology Center is not responsible for clothing, eyeglasses, denture, jewelry, money or any other personal articles of value kept in my possession while at Ohio Dermatology Center.
6. Title 42 CRF 420 requires that a physician notify the patient that the physician has a direct financial interest in a separate diagnostic or treatment agency to which the physician is referring the patient and/or in the non-routine goods or services being prescribed by the physician, and if these are available elsewhere on a competitive basis. We support this law because it helps patients make reasonable financial decisions concerning their medical care. In compliance with the requirements of this law, we have a direct financial interest in the diagnostic or treatment agency or in the non-routine good or services: Pathology Services. These services are available elsewhere on a competitive basis at various hospitals and surgical centers in Franklin County such as Mount Carmel East Hospital.
7. In accordance with Federal Law, Ohio Dermatology Center is notifying you that it will not honor advanced directives.
8. Under the Federal Law Health Insurance Portability and Accountability Act restricts Ohio Dermatology Center from discussing any medical information, unless a release form is signed.
I read this form or it has been read to me and I am satisfied that I understand its contents. I further understand that this consent will be deemed continuing and I am free to withdraw my consent at any time.
I received a copy of the Notice of Privacy Practices and Patients’ Rights and Responsibilities.
I acknowledge the Direct Financial Interest Disclosure.
I consent to pictures or videos being recorded or televised during my treatment, including appropriate portions of my body, for medical research or educational purposes, as long as my identity is not compromised or released.
I agree that you may call me on whatever phone numbers I give you, including land lines, cell phones, Skype numbers, or anything else.