Health Literacy Universal Precautions Toolkit, 2nd Edition

Consent to Treat Form

[Microsoft Word file Microsoft Word version - 21.89 KB]

  1. I                                      (patient name) give permission for [practice name] to give me medical treatment.
  2. I allow [practice name] to file for insurance benefits to pay for the care I receive.            

    I understand that:

    • [practice name] will have to send my medical record information to my insurance company.
    • I must pay my share of the costs.
    • I must pay for the cost of these services if my insurance does not pay or I do not have insurance.
  3. I understand:
    • I have the right to refuse any procedure or treatment.
    • I have the right to discuss all medical treatments with my clinician.

 

                                                                                                         

Patient's Signature                                                  Date

 

                                                                                                         

Parent or Guardian Signature                                   Date

(for children under 18)          

                                                                                                         

Print name

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Page last reviewed February 2015
Page originally created February 2015
Internet Citation: Consent to Treat Form. Content last reviewed February 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2-tool11d.html