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1. Parties: Identification of healthcare provider and patient
2. Background: Context of medical treatment or procedure
3. Definitions: Key terms used in the waiver including medical terminology
4. Scope of Treatment: Detailed description of medical procedures and treatments covered under this waiver
5. Acknowledgment of Risks: Comprehensive listing of potential risks, complications, and side effects
6. Waiver Statement: Explicit waiver of liability language and acknowledgment of understanding
7. Signature Block: Space for dated signatures of patient, healthcare provider, and witnesses if required
1. Emergency Contact Information: Section for patient's emergency contact details, recommended for high-risk procedures
2. Insurance Information: Details of patient's insurance coverage and billing arrangements
3. Alternative Treatment Options: Documentation of other available treatment choices and why they were not selected
4. HIPAA Privacy Notice: Additional privacy notices and acknowledgments when handling sensitive medical information
1. Schedule A - Detailed Procedure Description: Technical details and step-by-step description of the medical procedure
2. Schedule B - Risk Statistics: Statistical data and research information regarding procedure outcomes and associated risks
3. Schedule C - Post-Treatment Care Instructions: Comprehensive instructions for post-procedure care and recovery
4. Schedule D - State-Specific Disclaimers: Required legal disclaimers and notices specific to the state jurisdiction
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