By signing below, I authorize the clinics operating under the brands “Aster”, “Medcare” and “Access” within Aster DM Healthcare and their physicians, consultants, nurses, other medical and non-medical staff, other employees (collectively the “Authorized Persons”) to conduct any diagnostic examinations, tests and procedures, emergency treatment or services, all routine blood tests, diagnostic tests, scans, and procedures, (including x-rays, MRI’s, CT Scan, Ultrasound), administration and/or injection of pharmaceutical products and medications, laboratory examinations, medications, treatment or radiological, therapeutic procedures and treatments in the judgment of the authorized Persons, which are necessary to effectively assess and maintain my health, and to assess, diagnose and treat my illness or injuries and are deemed necessary or advisable for my curative, rehabilitative, conservative & palliative care.I undertake to inform authorized persons about all facts pertains to my health and previous medical history/allergies/specific conditions/ disabilities irrespective of its relevance to the procedure diagnosis or treatment proposed to be undertaken at the clinic. I acknowledge the fact that in case any of my disclosures are found to be untrue or incomplete, neither the clinic nor the authorized Persons would be responsible for any consequences thereof.I do acknowledge that informed consent may be needed for some specific diagnostic tests and surgical procedures.I do acknowledge that the result of medical treatment including the surgical procedures if any required, may not be adequately predicted, neither the clinic nor the authorized persons can give or is allowed to give full guarantee or confirmation on the outcome of the treatment including the surgical procedures I receive.I acknowledge the fact that the clinic has the authority to dispose of specimens taken for laboratory or pathological examination and I consent to the same. I hereby authorize clinic and authorized persons to review and/or release my personal health information to other healthcare providers for my better treatment during treatment.I hereby authorize and direct my insurance carrier and/or health care plan to make payment to clinics and hereby assign to clinics any and all rights, title and interest. I have insurance proceeds or benefits payable to me or on my behalf for services rendered to me by clinics. I understand that I am financially responsible to clinics for all charges, including those not paid by insurers or health care plans for services not authorized as specified in my benefit package, incurred by me or in my behalf.I have been explained about the patient rights and responsibilities.It is understood that we are not supposed to bring any valuables to the clinic and the clinic and authorized persons shall not be held responsible or liable for any loss or damage of these items.I hereby authorize and direct the clinic, and/or authorized Persons, to provide copies of all my medical records to government agencies, insurance companies, my family and relatives and others who are financially liable for my medical care, all information needed to substantiate payment for medical care.I understand that Aster DM Healthcare will collect and store information relevant to my health together with other information for the purposes of insurance, administration and financial matters, including personal contact details (Personal Information). I consent to Aster DM Healthcare using the Personal Information, and sharing the same (limited to the extent necessary) for legitimate purposes, and to meet statutory obligations, including:Sharing Personal Information with:(a) Other healthcare providers for the purposes of patient care;(b) My insurer, other third-party payers, agents and/or consultants for the purpose of reviewing, investigating, or processing any relevant claims for reimbursement and related matters; and(c) Any relevant government authority in accordance with statutory obligations.I also consent to Aster DM Healthcare to de-personalizing the Personal Information and sharing the same in a non- identifiable data format for the purposes of:(a) education;(b) research;(c) assessing Aster DM Healthcare quality standards and clinical performance; and(d) internal business processes.Our physicians may recommend that you are referred to another of our specialists, within Aster DM Healthcare or those affiliated with us. When any referral is recommended, we ensure that the referral is offered on the grounds of clinical need and in the best interests of our patients. You may not wish to take up the offer of a referral and you may seek the same treatment from a physician of your choice.I have read or have been read to in a language I can understand, and I completely understood the general consent and authorizations stated hereinabove, accept the above terms and conditions and agree to abide by said requirements herewith. I have read the details on my/the patient’s registration form and confirm that they are correct. I understand that my consent will remain in effect unless otherwise I explicitly stated or until my treatment is completed. The word “I” mentioned in this Consent Form shall mean and include the patient or patient’s representative or legal guardian, as applicable and signed herein.
