1. In seeking care from FORTE Men’s Health, I hereby consent to receive medical treatment and care from Forte Men’s Health and its authorized medical staff. This consent includes, but is not limited to, diagnostic procedures, medical treatments, and any other healthcare services deemed necessary by my healthcare provider. I understand that the practice of medicine is not an exact science and that no guarantees have been made to me regarding the outcome of any procedures or treatments.
2. Release of Liability. In consideration of the medical services provided to me, I hereby release and discharge FORTE Men’s Health, its officers, employees, and agents from any and all claims, demands, or causes of action that I may have now or in the future, arising out of\or in connection with the medical treatment and care provided to me. This release of liability does not apply to acts of gross negligence or willful misconduct.
3. HIPAA Compliance and Authorization for Use and Disclosure of Protected Health Information. I acknowledge that FORTE Men’s Health is required by law to maintain the privacy of my protected health information (PHI) in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its implementing regulations. I understand that my PHI may be used and disclosed for purposes of treatment, payment, and healthcare operations as permitted by HIPAA.
3.1 Authorization for Use and Disclosure. I authorize FORTE Men’s Health to use and disclose my PHI for the basis of planning my care and treatment and a means of communication among the many health professionals who contribute to my care.
I understand that I have the right to revoke this authorization in writing at any time, except to the extent that FORTE Men’s Health has already taken action in reliance on this authorization.
