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  • AUTHORIZATION FOR AND CONSENT TO NERVE CONDUCTION STUDY OR SPECIAL DIAGNOSTIC PROCEDURES AND AUTHORIZATION TO RELEASE MEDICAL RECORDS

  • Consent to Special Diagnostic Procedures

    My signature on this form indicates that: (1) I have read and understood the information provided in this form; (2) I have been provided with the opportunity to ask and receive answers to any questions I have about the Procedure; and (3) I authorize and consent to the performance of the Procedure by Precision Occupational Medical Group (POMG) physicians/staff.

    1. I hereby authorize and direct POMG physicians/staff to perform the following special diagnostic procedure upon me (the “Procedure") and to do any other diagnostic procedure and therapeutic procedure that their judgment may dictate to be advisable in case of emergency. Procedure: Nerve Conduction Study and Electromyography (EMG/NCS).
    2. I acknowledge that POMG physicians/staff have fully explained to me the nature and purpose of the Procedure and that such diagnostic or therapeutic procedure may involve calculated risks of complications and injury from both known and unknown causes, including but not limited to bruising, bleeding, nerve damage, worsening pain, or infection. I acknowledge that no warranty or guarantee has been made as to the results or cure regarding any ailment I may have. I acknowledge I have been informed of the nature and purpose of the procedure, the expected benefits, the risks of the complications, and the alternative methods of treatment, if applicable. I further recognize that I have the right to consent to or refuse the proposed special diagnostic or therapeutic procedure after consultation with POMG physicians/staff. Further, I recognize that this form is not intended to be a substitute for the explanations of the nature and purpose of the procedure, the expected benefits, the risks of complication, and the alternative methods of treatment, if applicable, which have been explained to me by POMG physicians/staff.
    3. I hereby authorize and direct POMG to provide such additional services for me as he/she or they deem reasonable and necessary.
    4. Your EMG/NCV report will be forwarded to your referring physician within 72 hours. Your referring physician will go over the test results with you and should be able to provide you a copy of your report, upon request. If you would like a copy of your EMG/NCV report sent directly to you from our office, please call our office 72 hours after the date of service to request at (855)EMGNCV1 or (949)955-0022.
    5. I may choose to have POMG’s on-site assistants help fill out my patient intake forms. I acknowledge that, depending on circumstances, this conversation may or may not be private and confidential, and that by so requesting assistance, I waive any confidentiality protection related to my personal health history. I understand that if I do not wish to waive these rights, I can complete the patient forms without PMG assistance.
    6. I hereby authorize POMG to release my records to my referring doctor.

    (NOTE: The below paragraph does NOT apply if you are a work-comp patient.)
    I understand, acknowledge and agree that I am financially responsible for any portions of the fees for services not paid for by my insurance company, including my deductible, co-insurance and any amount exceeding what my insurance company pays, except where exempt by contractual agreement. I further understand that I am responsible for complying with any requirements that my insurance carrier may have regarding referrals, prior approvals, pre-authorizations and second opinions, and that my failure to fully comply with my insurer’s requirements may result in the denial of the claim(s) related to the services being provided, and in such instance I am fully responsible to pay.

    I HAVE READ THE ABOVE AUTHORIZATION AND ACKNOWLEDGEMENT AND IT HAS BEEN FULLY EXPLAINED TO ME. I CERTIFY THAT I UNDERSTAND THE CONTENTS OF THIS FORM, THAT I HAVE BEEN PROVIDED THE OPPORTUNITY TO ASK AND RECEIVE ANSWERS TO ANY QUESTIONS I HAVE CONCERNING THE PROCEDURE, AND THAT I AM COMPETENT TO EXECUTE THIS CONSENT OR THAT I AM AUTHORIZED TO EXECUTE IT ON THE PATIENT'S BEHALF.

  • I understand and consent to the performance of the Procedure by [DOCTOR CHOSEN BELOW] and those under his immediate responsibility and supervision.
  • Date Format: MM slash DD slash YYYY