Consent For Treatment

Consent For Treatment & Financial Responsibility

Applies to Adult and Minor Patients

Georgia Epilepsy & Neurology Institute, LLC
4275 Johns Creek Parkway, Suite C
Suwanee, Georgia 30024
912-513-1041

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1. GENERAL CONSENT FOR MEDICAL CARE

I voluntarily consent to medical evaluation, examination, diagnostic testing, and treatment provided by the physicians, nurse practitioners, physician assistants, EEG technologists, medical assistants, and authorized clinical staff of Georgia Epilepsy & Neurology Institute, LLC.

  • Comprehensive neurological examinations
  • Evaluation and management of epilepsy, seizures, headaches, neuropathy, memory disorders, movement disorders, and other neurological conditions
  • EEG testing (routine, ambulatory, video EEG when applicable)
  • Diagnostic and laboratory testing
  • Prescription and management of medications
  • Care coordination and referrals
  • Telehealth services when appropriate

I understand that the practice of medicine is not an exact science and that no guarantees have been made regarding the results of my treatment.

2. CONSENT FOR EEG & DIAGNOSTIC PROCEDURES

If deemed medically necessary, I consent to EEG and related neurological diagnostic testing, including:

Placement of electrodes on the scalp Recording of brain wave activity Activation procedures such as hyperventilation and photic stimulation

I understand mild skin irritation, temporary discomfort, or fatigue may occur. All procedures will be explained prior to testing.

3. TELEHEALTH CONSENT (WHEN APPLICABLE)

I understand telehealth services may involve secure audio and/or video communication technology. I acknowledge that technical issues may occasionally occur, privacy protections remain in place, I may request an in-person visit when clinically appropriate, and I may withdraw consent for telehealth services at any time.

4. MINOR PATIENT CONSENT (IF PATIENT IS UNDER 18)

If the patient is under 18 years of age, I certify that I am the parent or legal guardian of the minor patient and have legal authority to consent to medical treatment.

I understand that both parents may have access to the minor’s medical information unless restricted by court order. It is my responsibility to provide any custody documentation that affects consent or disclosure rights. In the event of emergency care, treatment may be provided as medically necessary.

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5. FINANCIAL RESPONSIBILITY & ASSIGNMENT OF BENEFITS

I understand and agree that I am financially responsible for all services rendered. Co-payments, deductibles, and coinsurance are due at the time of service. If my insurance denies or does not cover services, I am responsible for the remaining balance. It is my responsibility to provide accurate and current insurance information.

I authorize the release of medical information necessary for insurance claim processing and assign payment of insurance benefits directly to Georgia Epilepsy & Neurology Institute, LLC.

Accounts not paid within a reasonable period may be subject to collection activity in accordance with applicable laws.

6. PRESCRIPTION MONITORING & CONTROLLED SUBSTANCES

I understand that certain medications, including controlled substances, are prescribed in accordance with Georgia and federal law. The provider may review the Georgia Prescription Drug Monitoring Program (PDMP) prior to prescribing applicable medications.

7. ACKNOWLEDGMENT OF NOTICE OF PRIVACY PRACTICES

I acknowledge that I have received or have been offered a copy of the Notice of Privacy Practices in compliance with the Health Insurance Portability and Accountability Act (HIPAA).

8. RIGHT TO ASK QUESTIONS OR WITHDRAW CONSENT

I understand that I have the right to ask questions regarding my care and may refuse or withdraw consent for treatment, except to the extent that action has already been taken in reliance on this consent.

Signatures

Signature Authorization*
If Patient is 18 Years of Age or Older:
Clear Signature
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If Patient is a Minor:
Clear Signature
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