Patient hereby voluntarily consents to wound care treatment by Oasis Healogy Clinic Wound Care Clinicians. Even though Patient has signed this form, Patient retains the right to refuse consent for any proposed procedure or treatment at any time prior to its performance.
1. General Description of Wound Care Treatment: Patient acknowledges that a Wound Care Clinician (WCC) has explained that treatment may include, but may not be limited to: debridement, dressing changes, administration of biologics, off-loading devices, physical examinations and treatment, diagnostic procedures, laboratory work (such as blood, urine and other studies), x-rays, other imaging studies and administration of medications prescribed or recommended by a physician, nurse practitioner or physician assistant. Patient acknowledges that the WCC has given Patient the opportunity to ask, and the WCC has answered any questions Patient had regarding the recommended wound care treatment.
2. Benefits of Wound Care Treatment: Patient acknowledges being advised that the benefits of wound care treatment include enhanced healing and reduced risks of amputation and infection.
3. Likelihood of Achieving Goals: Patient acknowledges being advised that by following the WCC's plan of care, Patient is more likely to have a better outcome, but that such treatment carries the risk of unsuccessful results, complications, and injuries, from both known and unforeseen causes. Therefore, Patient understands that there can be no warranties or guarantees of specific results.
4. General Description of Wound Debridement: Patient understands that wound debridement meansthe removal of unhealthy tissue from a wound to promote healing, and that during the course of treatment with Oasis Healogy Clinic, multiple wound debridements may be necessary.
5. Risks/Side Effects of Wound Debridement: Patient understands that the risks or complications of wound debridement include, but are not limited to: potential scarring, damage to blood vessels or surrounding areas such as organs and nerves, allergic reactionsto topical and injected local anesthetics or skin prep solutions, excessive bleeding, removal of healthy tissue, infection, ongoing pain and inflammation, and failure to heal. Patient specifically acknowledges that the WCC has explained that: bleeding after debridement may cause rapid deterioration of an already compromised patient; drainage of an abscess or debridement of necrotic tissue may result in dissemination of bacteria and bacterial toxins into the bloodstream and thereby cause severe sepsis; and debridement will make the wound larger due to the removal of necrotic (dead) tissue from the margins of the wound.
6. Patient Identification and Wound Images: Patient understands and consents to images (digital, film, etc.), being taken of all the Patient's wounds with their surrounding anatomic features. The purpose of these images is to monitor the progress of wound treatment and ensure continuity of care. Patient further agrees that their referring physician or other treating physicians may receive = communications,including these images, regarding Patient's treatment plan and results. The images are considered protected health information and will be handled in accordance with federal laws regarding the privacy,security, and confidentiality ofsuch information. Patient understandsthat Oasis Healogy Clinic will retain the ownership rights to these images, but that the patient will be allowed access to view them or obtain copies according to state and Federal law. Patient waives all rights to royalties or other compensation for these images.
7. Use and Disclosure of Protected Health Information (PHI): Patient consents to the use of PHI, results of patient's medical history and physical examination, and wound images obtained during the course of Patient's wound care treatment and stored in the wound database for purposes of, education, research, quality assessment and improvement activities, and development of proprietary clinical processes and healing algorithms. Patient's PHI may be disclosed to Oasis Healogy Clinic affiliated companies, and third parties who have executed a Business Associate Agreement. Any disclosure of Patient's PHI shall be in compliance with the privacy regulations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Patient specifically authorizes use and disclosure of patient' PHI by Oasis Healogy Clinic, its affiliates, and business associates for purposes related to treatment, payment, and health care operations. If Patient wishes to request a restriction to how his/her PHI may be used or disclosed, Patient may send a written request for restriction to the Corporate Address (to be provided per request).
8. Assignment of Benefits: Patient authorizes Oasis Healogy Clinic to bill their medical insurance for all medical treatment and wound care supplies and dressings, and also allows any medical information about patient to be released to any payor and their respective agent to determine benefits or the benefits payable for related services. The patient hereby acknowledges that he or she has read this document or had it read to him/ her and understands the contents herein. The Patient has had the opportunity to ask questions of the WCC and has received answers to all his or her questions. By signing below, Patient: (1) consents to the care, treatment, and services described in this document and orally by the WCC; (2) consents to the creation of images to record his or her wounds; and (3) consents to the transfer of health information protected by HIPAA between Oasis Healogy Clinic and its affiliated companies.