Disclosure and consent forms

Medical, surgical, diagnostic and/or therapeutic procedures, hemodialysis, intravenous contrast administration, central line insertions, blood transfusion, all forms of anesthesia and/or invasive procedure(s).

Yes. Only the MCD-MCHS approved facility consent will be accepted and the consent must be fully executed- It must be signed, dated, and timed by the patient, witness and surgeon / proceduralist. If witnessed by the office staff, they must sign and print their name. Physician Practice created consents will not be accepted.

The physician performing the medical or surgical procedure, the patient and/or legal surrogate, and the witness(es). Each must Print their name, Sign their name and Date-Time.

The physician must print their first and last name, sign, DATE and TIME the HCA Facility Consent with the appropriate Disclosure List (A-B) attached.

The patient signature should be obtained at the same time by either the physician or the physician’s office staff.

Patients who meet the criteria for giving consent but have a communication barrier, (i.e., hearing impaired, unable to comprehend English, etc.) shall be provided with an interpreter or interpretation services free of charge.

Patients who are visually impaired/blind will have the information read to them in the presence of a witness, if requested. (Refer to process for Telephone/Verbal Consent)

When an interpreter is used to explain the form to the patient, the consent requires a witness signature and completion of the Authorization/Completion Code- name or ID of the interpreter and be documented on the consent.