Internal Medicine Treatment Agreement and Informed Consent

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record #: ______________ Date: ___________________

Agreement Terms

1. Consent for Treatment

I, the undersigned patient, consent to medical evaluations, treatments, and procedures recommended by my physician at [PRACTICE NAME]. I understand that the practice of medicine is not an exact science, and no guarantees have been made regarding the outcome of my treatments.

2. Patient Responsibilities

• Provide accurate and complete medical history
• Inform the physician of any changes in health status
• Follow the agreed-upon treatment plan
• Keep scheduled appointments or provide 24-hour notice of cancellation
• Take medications as prescribed
• Maintain current and accurate insurance information

3. Practice Responsibilities

• Provide professional medical care following current clinical guidelines
• Maintain patient confidentiality per HIPAA regulations
• Provide timely access to medical care
• Explain treatment options and potential risks/benefits
• Coordinate care with other healthcare providers when necessary

4. Communication

• Office hours: [HOURS]
• Emergency contact procedures: [PROCEDURES]
• Patient portal usage guidelines
• Prescription refill policy

5. Financial Agreement

• Insurance billing procedures
• Co-payment and deductible responsibilities
• Self-pay payment expectations
• Outstanding balance policies

Acknowledgment

I have read and understand this agreement. I have had the opportunity to ask questions, and I agree to its terms.

Patient Signature: _________________________ Date: ____________

Physician Signature: _______________________ Date: ____________

Witness: _________________________________ Date: ____________