MedicalConsentToTreat

Consent to Medical Treatment
497 Mall Road | Oak Hill, WV 25901 | P: 304-469-2905 | F: 304-465-5486

Patient's Name

Date of Birth

YYYY

Phone number

Patient Address

Name of Custodial Parent or Legal Guardian:

I voluntarily consent to medical treatment by clinical staff of the New River Health Association, Inc. (NRHA) including care by physicians, physician assistants, nurse practitioners, nurse midwives, dentists, dental hygienists, optometrists, and mental health professionals (collectively referred to as NHRA Providers); for myself or the above person for whom I am a custodial parent or legal guardian. I authorize the NRHA Providers to perform healthcare examination, treatment, diagnostic testing or medication administration as deemed medically necessary based on the NRHA Providers judgment. As part of my routine medical care, I further consent to have NRHA conduct blood-borne infectious disease testing, including but not limited to, testing for Hepatitis and Human Immunodeficiency Virus (“HIV”), if a NRHA Provider orders such tests in accordance with medical necessity guidelines or other recognized protocol. I understand that the potential side effects and complications of this testing are generally minor and are comparable to the routine collection of blood specimens, including discomfort from the needle stick and/or slight burning, bleeding or soreness at the puncture site. The results of any such testing will become part of my confidential medical record.<br><br>I have read, or have had read to me, the above consent. I have had an opportunity to ask questions about its content, and by signing below I agree to the above named medical services.

Signature

Date

2025

I DO NOT wish to receive HIV testing as part of my routine medical care.

Signature

Date

2025

Authorization to Pay Medical Insurance Benefits to New River Health Association

I hereby choose NRHA and the healthcare professionals that work at NRHA to provide medical care to me or my dependent whose name appears above. I make this choice willfully. In consideration of the medical services rendered by NRHA, I hereby assign, transfer and give to NRHA all of my rights, title and interest to medical expense reimbursement benefits under any insurance policy, subscription certificate, Medicare benefits or any other public or private health care benefit indemnification program or agreement otherwise payable to me for those services rendered by NRHA. This agreement specifically includes, but is not limited to, an assignment of the rights to designate a beneficiary, add dependent eligibility, obtain payment of any other third-party liability policy medical expense benefits due for this treatment and to have an individual or group policy converted in accordance with its terms and benefits.<br><br>I authorize the payment of medical insurance benefits to the NRHA for services provided and I authorize the release of medical information necessary to process insurance claims related to such services. I know that I must pay for any charges for my care that are not covered by my insurance, health plan or government programs. I realize I must cooperate with NRHA to get payment for my care. This includes assisting with clearing up any disputes about charges. I understand that I will be fully responsible for payment of the balance due as consideration of medical services provided by NRHA.

Signature

Date

2025

Authorization Granted Another Competent Adult to Grant Consent to Treatment

As the custodial parent or legal guardian of:

I hereby grant authority to the following people to give consent to medical treatment, including immunizations or other necessary prevention or sickness-related health services for the above named patient:

1. (Competent Adult)

2. (Competent Adult)

Signature

Date

2025

HIPAA Notice Of Privacy

I have received the New River Health Association Notice of Privacy Practices, which describes the ways in which NRHA may use and disclose my healthcare information for its treatment, payment, healthcare operations and other prescribed and permitted uses and disclosures. I understand that this information may be disclosed electronically by NRHA and/or NRHA’s business associates. I understand that I may contact the NRHA Privacy Officer designated on the notice if I have a question or complaint.

SIgnature

Date

2025

In Case of Emergency Contact the Person Below:

Name

Address

Home/Cell #

Work #

Relationship

Date

2025