Consent for Treatment
I understand that I will be receiving wound care services from Alliance Wound Care Services. These services may involve wound evaluations, cleanings, dressings, debridement, and use of specialized medical products.
I recognize that while these treatments aim to improve healing, they may carry risks including pain, infection, or delayed healing. I understand I have the right to decline specific treatments and acknowledge that doing so may impact the overall effectiveness of my care.
Health Information Usage
I consent to the use and sharing of my health information by Alliance Wound Care Services for care coordination, billing, and clinical operations. This may include communication via phone, voicemail, email, or postal mail. I understand I may revoke this consent at any time in writing, and doing so will not affect information previously shared. Alliance Wound Care Services complies with all applicable federal regulations, including the Health Insurance Portability and Accountability Act (HIPAA), to ensure the protection and privacy of patient health information.
Release of Protected Health Information
I understand that my alcohol and/or drug treatment records are protected under the Federal regulations governing Confidentiality or Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. pts 160 & 164. I understand that my health information specified above will be disclosed pursuant to this authorization, that the recipient of the information may re-disclose the information, and it may no longer be protected by the HIPAA privacy law. The Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, noted above, however, will continue to protect the confidentiality of information that identifies me as a patient in an alcohol or other drug program from re-disclosure. I understand that I may revoke this consent in writing at any time except to the extent that action has been taken in reliance on it, and that this consent will expire in one (1) year unless otherwise specified.
Medication History Authorization
I authorize Alliance Wound Care Services to access my prescription history from pharmacies, insurance plans, and other healthcare providers. I understand that sharing my over the counter and herbal remedies is also important to ensure a complete and safe treatment plan.
Notice of Privacy Practices
I acknowledge that I have received or been made aware of Alliance Wound Care Services' Privacy Practices. I understand that I have rights to access, restrict, or request corrections to my health information and can revoke this consent at any time with written notice.
Your Rights as a Patient
- To receive care, free of discrimination, with respect and compassion
- To be involved in decisions about your care
- To ask questions and receive clear answers about your diagnosis and treatment
- To expect privacy and confidentiality
- To request access to your health records
- To have an interpreter if needed
Your Responsibilities as a Patient
- Provide accurate and complete medical history
- Follow care instructions and attend scheduled appointments
- Inform the clinic of any inability to comply with the care plan
- Be courteous to staff and other patients
- Respect clinic policies and property
- Make healthy lifestyle choices that support healing
Appointments & Cancellation Policy
Please contact us at least 24 hours in advance if you need to cancel or reschedule. Failure to do so may result in a $50 no-show fee. Repeated no-shows or cancellations may result in discharge from care. If you experience an emergency, we encourage you to contact our office so we can support your continued treatment.
Wound Photography Consent (for Clinical Use)
I give permission for Alliance Wound Care Services to take clinical photographs of my wound(s) to support medical evaluation, documentation, and treatment planning. These photos will be securely stored and only used for purposes related to my care. I may revoke this consent at any time in writing. Photographs already taken will remain in my medical record.
Photography Consent for Marketing Purposes
I give permission to Alliance Wound Care Services to use photographs of my wound(s) for marketing, educational, or promotional purposes, including on digital platforms, printed materials, and presentations. I understand that identifiable features such as my face, name, or other personal identifiers will be concealed or removed to ensure my privacy is protected. I may revoke this consent at any time in writing. Revocation will not apply to photos already used in previously distributed materials.
Financial Agreement
I understand that:I am responsible for costs not covered by insurance (e.g., co-pays, deductibles), Insurance verification is not a guarantee of payment, A $25 fee may apply to returned payments, I should contact Alliance Wound Care Services if I experience financial difficulty; payment arrangements may be possible. Our goal is to ensure care is accessible. If you need help, please contact our billing team.
This clinic complies with Washington’s surprise billing and consumer protection laws.
Acknowledgment & Consent
I confirm that I have read and understand the contents of this document. I agree with the terms stated above and give my consent to receive care from Alliance Wound Care Services.