Microsoft word - consent for treatment

ECONOMIC SECURITY CORP. OF SW AREA/WOMEN’S HEALTH CARE 302 JOPLIN, JOPLIN, MO 64801 PHONE 417-781-4788 REQUEST FOR TREATMENT AND PRESCRIPTION OR INSERTION OF CONTRACEPTIVE DRUG, DEVICE OR METHOD. I hereby request that a person authorized by Economic Security Corporations Women’s Health Care & Family Planning program examine and treat me and that a suitable contraceptive drug, device or method be prescribed or fitted. I request that I be given___________________by the physician and/or Nurse Practitioner at the Women’s Health Care Clinic sponsored by ESCSWA, in order to prevent pregnancy. I understand that this consent will be valid until rescinded by me. ____ Depo Provera injection ___ Pills I have received a fact sheet containing information on the use, effectiveness, and known risks of the available contraceptive drugs; including oral contraceptives (birth control pills), Depo-Provera (the shot), the diaphragm, contraceptive patches, and other contraceptive methods. I have received information and counseling about the importance of being immunized against Rubella and Hepatitis B. No guarantee or assurance has been made to me as to the results that may be obtained if I use any of the methods described in the Fact Sheet. I am aware on the basis of the Fact Sheet and the explanation I received of the possible adverse consequences and side effects, as well as the potential benefits, of the various methods as set forth in the Fact Sheet. I also authorize the customary medical procedures, which may include, TB screening tests or screening test for anemia, diabetes, hypertension, sexually transmitted infections, pregnancy, Rubella and cancer. I have been provided the Notice of Privacy Practices for the Economic Security Women’s Health Care Clinic. I understand, I am to notify my health care provider, emergency room or county health department of any difficulties that may arise. I realize that if tests are taken for sexually transmitted infections, law requires reporting of positive results to the Missouri Department of Health. I understand that my records may be inspected at your office by representatives of the Missouri Family Health Council or the Missouri Department of Health for the purpose of verifying the income, the services and quality of care provided to me. I understand that representatives of either agency will keep all information contained in such records in strictest confidence. I understand that under federal law (Section 7 of the Privacy Act of 1974, 42 U.S.C. 405) that the disclosure of my Social Security Number is voluntary and that if I refuse to disclose my Social Security Number I will not be denied the Women’s Health Care & Family Planning services I will receive today. I consent to the release of required program information on myself to the Women’s Health Care & Family Planning program administered by the Missouri Department of Health. I understand this information will be used in generating statistical reports that provide data to evaluate the program, determine payments to the clinics, and determine quality improvement outcomes. Identifying information will be utilized for payment purposes only. Signature of Patient________________________________________Date___________________________ I witness the fact that the patient received and said she read and understood the Fact Sheet. Staff Signature_________________________________________Date_____________________________ This form was translated and witnessed by an interpreter. Staff Signature______________________________

Source: http://www.escswa.org/view/238.pdf