Cardiology Authorization for Treatment Form

Patient Information

Name: _________________________________ Date of Birth: //___ Medical Record #: ________________________ Date: //___

Authorization Statement

I, the undersigned patient/legal representative, hereby authorize [CARDIOLOGY PRACTICE NAME] and its affiliated healthcare providers to provide cardiac care and treatment, including but not limited to:

• Physical examinations and assessments
• Diagnostic testing and procedures
• Cardiac monitoring and evaluation
• Administration of medications and treatments
• Emergency interventions when medically necessary

Acknowledgments

By signing this form, I acknowledge and agree that:

1. I understand the nature of the proposed treatments and procedures
2. I am aware of the potential risks, benefits, and alternatives
3. I have had the opportunity to ask questions and receive answers
4. I understand that no guarantees have been made regarding outcomes
5. I consent to emergency treatment if needed during my care

Financial Responsibility

I understand that:

• I am responsible for any charges not covered by my insurance
• Payment is expected at the time of service unless other arrangements are made
• Insurance authorization is not a guarantee of payment

Signatures

Patient/Legal Representative: ___________________________ Date: //___

Witness: __________________________________________ Date: //___

Physician: ________________________________________ Date: //___

Practice Information

[Practice Name] [Address] [Phone Number] [License Information]