Patient hereby voluntarily consents to wound care treatment by AcuHeal Wound Specialists and their respective employees, agents, representatives, and affiliated companies. Patient understands that this Consent Form will be valid and remain in effect from the date of signature, as long as Patient receives care, treatment and services at the AcuHeal Wound Specialists. Patient has the right to give or refuse consent to any proposed procedure or treatment at any time prior to its performance.
1. General Description of Wound Care Treatment: Patient acknowledges that Physician has
explained that treatment in the AWS may include, but shall not be limited to: debridements,
dressing changes, biopsies, skin grafts, off-loading devices, physical examinations and treatment,
diagnostic procedures, laboratory work (such as blood, urine and other studies), x-rays,
hyperbaric oxygen therapy, other imaging studies and administration of medications prescribed
by a physician. Patient acknowledges that Physician has given Patient the opportunity to ask,
Patient has asked, and Physician has answered all Patient’s questions regarding the treatments that
may be provided in the AWS.
2. Benefits of Wound Care Treatment: Patient acknowledges that Physician has explained that
the benefits of treatment in the AWS include: enhanced wound healing and reduced risks of
amputation and infection.
3. Risks/Side Effects of Wound Care Treatment: Patient acknowledges that Physician has
explained that treatment in the AWS may cause side effects and risks including, but not be limited
to: infection, ongoing pain and inflammation, potential scarring, possible damage to blood
vessels, possible damage to surrounding tissues, possible damage to organs, possible damage to
nerves, bleeding, allergic reaction to topical and injected local anesthetics or skin prep solutions,
removal of healthy tissue, and prolonged healing or failure to heal.
4. Likelihood of achieving goals: Patient acknowledges that Physician has explained that by
following the Physician’s plan of care he or she is more likely to have a better outcome; however,
any procedures/treatments carry the risk of unsuccessful results, complications, and injuries, from
both known and unforeseen causes. Therefore, Patient specifically agrees that no representation
made to him or her by Physician, Hospital or HI constitutes a Warranty or Guarantee for any
result or cure.
5. Alternative to Wound Care Treatment: Patient acknowledges he or she has been made
aware that he or she may refuse treatment in the AWS Patient acknowledges that if he or she
refuses treatment in the AWS, he or she will not gain the benefits of treatment (see Benefits of
Wound Care Treatment above). In lieu of treatment in the AWS, Patients may continue a course
of treatment with his or her personal physician or forego any treatment.
6. Benefit of Alternative to Wound Care Treatment: Patient acknowledges that Physician has
explained that if he or she chooses to continue a course of treatment with his or her personal
physician or forego any treatment, he or she may not experience the risks/side effects
associated with treatment in the AWS (see Risks/Side Effects of Wound Care
Treatment above).
7. Risks/Side Effects of Alternative for Wound Care Treatment: Patient acknowledges that
Physician has explained that the risks of alternative wound care treatment include prolonged
healing or failure to heal, infection and possible amputation if wound is on a limb.
8. General Description of Wound Debridements: Patient acknowledges that Physician has
explained that wound debridement means the removal of unhealthy tissue from a wound to
promote healing. During the course of treatment in the AWS, multiple wound debridements may
be necessary and will be performed by an authorized practitioner.
9. Risks/Side Effects of Wound Debridement: Patient acknowledges that Physician has
explained that the risks or complications of wound debridement include, but are not limited to:
potential scarring, possible damage to blood vessels or surrounding areas such as organs and
nerves, allergic reactions to topical and injected local anesthetics or skin prep solutions, excessive
bleeding, removal of healthy tissue, infection, ongoing pain and inflammation, and failure to heal.
Patient specifically acknowledges that Physician has explained that bleeding after debridement
may cause rapid deterioration of an already compromised patient. Patient specifically
acknowledges that Physician has explained that drainage of an abscess or debridement of necrotic
tissue may result in dissemination of bacteria and bacterial toxins into the bloodstream and
thereby cause severe sepsis. Patient specifically acknowledges that Physician has explained that
debridement will make the wound larger due to the removal of necrotic (dead) tissue from the
margins of the wound.
10. Patient Identification and Wound Images: Patient understands and consents that images
(digital, film, etc.), may be taken by the AWS of Patient and all Patient’s wounds with their
surrounding anatomic features. The purpose of these images is to monitor the progress of wound
treatment and ensure continuity of care. Patient further agrees that their referring physician or
other treating physicians may receive communications, including these images, regarding
Patient’s treatment plan and results. The images are considered protected health information and
will be handled in accordance with federal laws regarding the privacy, security and
confidentiality of such information. Patient understands that the AWS will retain the ownership
rights to these images, but that the patient will be allowed access to view them or obtain copies
according to state and Federal law. Patient understands that these images will be stored in a
secure manner that will protect privacy and that they will be kept for the time period required by
law and/or hospital policy. Patient waives any and all rights to royalties or other compensation for
these images. Images that identify the Patient will only be released and/or used outside the AWS
upon written authorization from the Patient or Patient’s legal representative.
11. Use and Disclosure of Protected Health Information (PHI): Patient consents to HI’s use
of PHI, results of patient’s medical history and physical examination, and wound images obtained
during the course of Patient’s wound care treatment and stored in the HI wound database for
purposes of, education, research, quality assessment and improvement activities, and
development of proprietary clinical processes and healing algorithms. Patient’s PHI may be
disclosed by HI to its affiliated companies, and third parties who have executed a Business
Associate Agreement. Disclosure of Patient’s PHI shall be in compliance with the privacy
regulations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Patient
specifically authorizes use and disclosure of patient's PHI, its affiliates, and business associates
for purposes related to treatment, payment, and health care operations. If Patient wishes to
request a restriction to how his/her PHI may be used or disclosed, Patient may send a written
request for restriction to A Chief Compliance Officer (CCO) at P.O. BOX 997377, MS 0504
Sacramento,Ca 95899-7377. If the PHI is owned by the Hospital or another entity, HI will direct
Patient's request to the appropriate party.
12. Financial Responsibility: Patient understands that regardless of his or her assigned
insurance benefits, Patient is responsible for any amount not covered by insurance. Patient
authorizes medical information about Patient to be released to any payor and their respective
agent to determine benefits or the benefits payable for related services.
The patient hereby acknowledges that he or she has read and agrees to the content of sections 1
through 12 of this document. Patient agrees that his or her medical condition has been explained
to him or her by the Physician. Patient agrees that the risks, benefits and alternatives of all care,
treatment and services that Patient will undergo while a patient at the AWS have been discussed
with Patient by Physician. Patient understands the nature of his or her medical condition, the
risks, alternatives and benefits of treatment, and the consequences of failure to seek or delay
treatment for any conditions. Patient has read this document or had it read to him/her and
understands the contents herein. The Patient has had the opportunity to ask questions of the
Physician and has received answers to all of his or her questions.
By signing below, Patient: (1) consents to the care, treatment, and services described in this
document and orally by the Physician, (2) consents to the creation of images to record his or her
wounds; and (3) consents to the transfer of health information protected by HIPAA between
Physician, Hospital and HI.