Consent Forms

Form Name HH-DPC# Rev. Posted
Authorization For...
Generic Informed Consent (English) 571084 11/11 11/21/11
Generic Informed Consent (Spanish) 571127 11/11 11/21/11
Anterior Cervical Discectomy 577171 01/12 02/20/12
Arterial Catheter, Central Venous Catheter and Pulmonary Artery Catheter Placement and Replacement in the ICU 571330 01/10 09/20/11
Audio/Video EEG Monitoring (English/Spanish) 571024 01/13 01/09/13
Bloodless Medicine & Surgery - Advance Directive (English & Spanish) 571041 10/13 02/04/14
Bloodless Medicine & Surgery - Refusal of Blood Transfusion/Minors (English & Spanish) 571157 03/14 04/29/14
Bloodless Medicine & Surgery - Release Form (English & Spanish) 571158 05/12 10/05/12
Bloodless Medicine & Surgery - Revocation of Refusal of Blood and Blood Derivatives (English & Spanish) 571705 03/14 04/29/14
Breast Surgery (English) 572300 12/12 12/17/12
Breast Surgery (Spanish) 572300-SP 06/12 06/27/12
Bronchoscopy with or without Biopsy (English) 572095 08/11 08/26/11
Bronchoscopy with or without Biopsy (Spanish) 572125 08/11 08/26/11
Bronchoscopy (with or without Biopsy) in the ICU 571331 07/11 07/26/11
Electroconvulsive (ECT) Treatment (English) 577195 08/11 08/08/11
Electroconvulsive (ECT) Treatment (Spanish) 577205 08/11 08/08/11
Electrophysiology/Arrhythmia Services (Invasive) 577110 11/12 11/27/13
Electrophysiology/Arrhythmia Services (Non-Invasive) 577110-A 11/13 11/27/13
Endometrial Biopsy and/or Sonohysterogram 577227 10/12 11/01/12
EP Study with Mapping and Ablation (English) 577016 11/12 11/21/12
EP Study with Mapping and Ablation (Spanish) 577016-SP 11/12 11/21/12
ERCP/Endoscopic Ultrasound (English) 577082 03/15 04/30/15
ERCP/Endoscopic Ultrasound (Spanish) 577083 02/13 02/19/13
Eye Center Surgery and/or Special Procedure/Treatment 572253 05/11 05/23/12
Extracorporeal Membrane Oxygenation (ECMO) 577248 04/14 06/18/14
Flexible Fiberoptic Laryngoscopy (English) 577211 04/15 04/24/15
Flexible Fiberoptic Laryngoscopy (Spanish) 577211-SP 04/15 04/24/15
Genetic Amniocentesis 572024 02/12 03/01/12
Hernia Center: Inguinal Hernia Repair 577222 07/12 10/05/12
Hernia Center: Ventral Hernia Repair 577224 08/12 10/05/12
Hyperbaric Oxygen 571636 06/12 10/11/12
Hysterectomy (English) 577022 11/12 11/21/12
Hysterectomy (Spanish) 577022-SP 11/12 11/21/12
Insertion/Removal of Implanon/Nexplanon 577228 10/12 11/01/12
Infant Drug Screening (English/Spanish) 577232 12/12 01/09/13
Intrauterine Device Insertion and/or Removal (English/Spanish) 577231 12/12 01/09/13
Laparoscopic Cholecystectomy 577223 08/12 10/05/12
Laparoscopic Hysterectomy 577250 04/14 06/17/14
Laparoscopic Myomectomy 577249 04/14 06/17/14
Laparoscopic Nissen Fundoplication/Paraesophageal Hernia Repair 577225 08/12 10/05/12
Laparoscopic Prostatectomy 577164 11/12 11/08/12
LDL Apheresis 572077 12/12 12/17/12
Left Ventricular Assist Device Insertion 577165 10/15 02/24/20
Left Ventricular Assist Device Insertion for Long-Term Circulatory Support 577165-A 10/19 02/24/20
Loop Electrical Excision Procedure of the Cervix 577229 10/12 11/01/12
Lumbar Discectomy 577174 02/12 02/17/12
Lumbar Puncture (English & Spanish) 572039 11/12 11/08/12
Lumbar Spinal Fusion 577173 01/12 02/10/12
MitralClip Procedure 577246 03/14 06/17/14
Medications Not Positively Identified 577213 04/12 04/30/12
Nephrectomy Surgery (English) 572153 09/11 09/09/11
Nephrectomy Surgery (Spanish) 572153-SP 10/11 11/02/11
Newborn Circumcision (English) 577103 06/12 07/23/12
Newborn Circumcision (Spanish) 577104 11/01 10/19/12
Open Heart Surgery (English) 577070 12/11 12/19/11
Open Heart Surgery (Spanish) 577071 12/11 12/19/11
Oral Surgery (English) 577088 12/11 12/05/11
Oral Surgery (Spanish) 577094 12/11 12/05/11
Ovarian Vein Embolization (English) 577121 11/11 11/21/11
Ovarian Vein Embolization (Spanish) 577161 11/11 11/21/11
Pacemaker/AICD (Automatic Cardioverter Defibrillator) (English) 577000 11/12 11/21/12
Pacemaker/AICD (Automatic Cardioverter Defibrillator) (Spanish) 577000-SP 11/12 11/21/12
Percutaneous Gastrotomy/Jejunostomy 577214 04/12 07/12/12
Percutaneous Procedures (English) 577005 11/11 11/21/11
Percutaneous Procedures (Spanish) 577005-SP 11/11 11/21/11
Percutaneous Transhepatic Cholangiogram/Biliary Drainage/Stent Placement (English) 577006 11/11 11/21/11
Percutaneous Transhepatic Cholangiogram/Biliary Drainage/Stent Placement (Spanish) 577027 11/11 11/21/11
Peripheral Angiography – Interventional (English) 571134 02/13 02/14/13
Peripheral Angiography – Interventional (Spanish) 577018 11/12 11/08/12
PICC or Midline Catheter 571310 11/11 11/21/11
Cancer Consents:
Consent to receive cancer therapies (English & Spanish) 577268-ENG-SP 12/15 06/30/16
Consent to receive cancer therapies (English & Polish) 577268-ENG-POL 12/15 06/30/16
Consent to receive cancer therapies (Italian) 577268-ITA 12/15 06/30/16
Hereditary Cancer Genetic Testing, General (English) 571325 10/12 10/04/12
Hereditary Cancer Genetic Testing, General (Spanish) 571325-SP 10/12 11/01/12
Hereditary Cancer Genetic Testing for APC and MYH (English) 571326 10/12 10/04/12
Hereditary Cancer Genetic Testing for APC and MYH (Spanish) 571326-SP 10/12 11/01/12
Hereditary Cancer Genetic Testing for BRCA1 and BRCA2 (English) 571327 10/12 10/04/12
Hereditary Cancer Genetic Testing for BRCA1 and BRCA2 (Spanish) 571327-SP 10/12 11/01/12
Hereditary Cancer Genetic Testing for Lynch Syndrome (English) 571328 10/12 10/04/12
Hereditary Cancer Genetic Testing for Lynch Syndrome (Spanish) 571328-SP 10/12 11/01/12
Hereditary Cancer Risk Assessment Provider Referral Fax Notification (English) 571807 11/09 01/14/10
Hereditary Cancer Risk Assessment Provider Referral Fax Notification (Spanish) 571783 09/09 01/14/10
Capsule Endoscopy 577086 02/13 05/12/15
Cardiac Catheterization/Percutanous Coronary Interventions (English) 577013 11/12 12/17/12
Cardiac Catheterization/Percutanous Coronary Interventions (Spanish) 577013-SP 11/12 11/21/12
Cataract Surgery With Intraocular Lens Implant (English) 572251 03/12 03/19/12
Cataract Surgery With Intraocular Lens Implant (Spanish) 572251-SP 03/12 03/19/12
Connecticut Children's/Hartford Hospital Combined Consent Form (English & Spanish) 571097 03/11 03/24/11
Colonoscopy/Endoscopy/Sigmoidoscopy/Polypectomy 577080 05/14 06/17/14
Colonoscopy/Endoscopy/Sigmoidoscopy/Polypectomy with Fecal Transfer 577080A 05/14 06/17/14
Colorectal Surgery (English) 577125 10/12 12/20/12
Colorectal Surgery (Spanish) 577200 06/12 11/01/12
Colposcopy with Cervical biopsies and Local Excisions 577230 10/12 11/01/12
Consent to Transfer (EMTALA Consents) as Recommended by Provider 571670 01/12 01/24/12
Craniotomy 577172 01/12 02/10/12
Cystectomy (English) 577220 10/12 10/09/12
Cystectomy (Spanish) 577220-SP 10/12 10/11/12
Dialysis Consents:
Dialysis Patient/Dialysis Treatment Facility Agreement (English) 571742 03/11 03/24/11
Dialysis Patient/Dialysis Treatment Facility Agreement (Spanish) 571742-SP 06/12 07/12/12
Continuous Veno-Venous Hemodialysis (English) 577252 04/14 06/17/14
Continuous Veno-Venous Hemodialysis (Spanish) 577252-SP 04/14 12/17/14
Hemodialysis (English) 571514 03/11 07/12/12
Hemodialysis (Spanish) 571514-SP 03/11 03/24/11
Peritoneal Dialysis (English) 571756 01/02 03/10/15
Peritoneal Dialysis (Spanish) 571756-SP 03/15 03/10/15
Therapeutic Plasma Exchange (TPE) (English) 577251 04/14 06/17/14
Therapeutic Plasma Exchange (TPE) (Spanish) 577251-SP 04/14 12/17/14
Radiation Therapy Consents:
Consent for Radiation Therapy (English) 577145 05/12 05/31/12
Consent for Radiation Therapy (Spanish) 577187 05/12 05/31/12
Abdominal/Lower Back Area (English) 577131 05/12 05/31/12
Abdominal/Lower Back Area (Spanish) 577151 05/12 05/31/12
Brain (English) 577132 06/10 05/30/12
Brain (Spanish) 577152 11/10 05/30/12
Breast-Only Area (English) 577135 12/12 01/09/13
Breast-Only Area (Spanish) 577135-SP 02/13 02/14/13
Breast Area and Adjacent Lymph Nodes (English) 577134 12/12 01/09/13
Breast Area and Adjacent Lymph Nodes (Spanish) 577184 05/12 06/01/12
Chest/Upper Back Area (English) 577136 05/12 06/01/12
Chest/Upper Back Area (Spanish) 577182 05/12 06/01/12
Chest Wall/Adjacent Lymph Nodes (English) 577137 05/12 05/31/12
Chest Wall/Adjacent Lymph Nodes (Spanish) 577183 05/12 05/31/12
Craniospinal Area (English) 577138 05/12 05/31/12
Craniospinal Area (Spanish) 577185 05/12 05/31/12
Extremities (English) 577139 05/12 06/01/12
Extremities (Spanish) 577186 05/12 06/01/12
Head and Neck Area (English) 577146 05/12 06/01/12
Head and Neck Area (Spanish) 577188 05/12 06/01/12
Hodgkin's/Non-Hodgkin's Lymphoma Mantle (English) 572131 05/12 06/01/12
Hodgkin's/Non-Hodgkin's Lymphoma Mantle (English) 572131-SP 05/12 06/01/12
Partial Breast Only (English) 572132 12/12 01/09/13
Partial Breast Only (Spanish) 572132-SP 05/12 06/01/12
Prevention of Heterotopic Bone (English) 577147 05/13 06/11/12
Prevention of Heterotopic Bone (Spanish) 577189 05/12 06/01/12
Pelvic/Reproductive Organs (English) 572145 05/12 06/01/12
Pelvic/Reproductive Organs (Spanish) 572146 05/12 06/01/12
Pelvis Including Prostate (English) 577133 05/12 05/31/12
Pelvis Including Prostate (Spanish) 577153 05/12 05/31/12
Permanent, Interstitial Brachytherapy to the Prostate (English) 577148 05/12 05/31/12
Permanent, Interstitial Brachytherapy to the Prostate (Spanish) 577180 05/12 05/31/12
Ra223 577241 01/14 06/18/14
SM-153 577239 01/14 06/18/14
Vagina/Vaginal Cuff (English) 577130 04/12 05/09/12
Vagina/Vaginal Cuff (Spanish) 577150 04/12 05/30/12
Y-90 Zevalin 577240 01/14 06/18/14
Radiology Consents:
Diagnostic Arteriogram/Angiogram/Embolization (English) 577123 11/11 11/21/11
Diagnostic Arteriogram/Angiogram/Embolization (Spanish) 577163 11/11 11/21/11
Image-guided Hemiogram (English) 577120 11/11 11/21/11
Image-guided Hemiogram (Spanish) 577160 11/11 11/21/11
Image-guided Paracentesis (English) 577119 11/11 03/01/12
Image-guided Paracentesis (Spanish) 577159 11/11 03/01/12
Image-guided Percutaneous Biopsy (English) 577122 11/11 11/21/11
Image-guided Percutaneous Biopsy (Spanish) 577122-SP 11/11 11/21/11
Image-guided Thoracentesis (English) 577118 11/11 11/21/11
Image-guided Thoracentesis (Spanish) 577158 11/11 11/21/11
Medical Clearance Form for Interventional Radiology Procedure (Anticoagulation) 572496 09/15 09/23/15
Medical Clearance Form for Interventional Radiology Procedure (Coagulation) 572497 09/15 09/23/15
Right Heart Catheterization/Right Ventricular Biopsy (English) 577166 02/12 03/09/12
Right Heart Catheterization/Right Ventricular Biopsy (Spanish) 577166-SP 02/12 03/09/12
Roux-en-Y Gastric Bypass 577034 11/12 12/17/12
Spermatic Vein Embolization/Varicocele Treatment/Venogram (English) 577116 11/11 11/23/11
Spermatic Vein Embolization/Varicocele Treatment/Venogram (Spanish) 577156 11/11 11/23/11
Surgical Tracheostomy 577236 06/14 06/17/14
Thyroid/Parathyroid Surgery 577226 10/12 10/29/12
Transcatheter Aortic Valve Replacement (TAVR) 577143 02/12 02/29/12
Transcatheter Aortic Valve Replacement (TAVR) Supplement 577144 01/12 02/08/12
Transesophageal Echocardiogram 577254 07/14 09/23/14
Transesophageal Echocardiogram with Cardioversion (English) 577255 07/14 09/23/14
Transesophageal Echocardiogram with Cardioversion (Spanish) 577255-SP 07/14 09/23/14
Transfusion Blood/Blood Products (English) 577090 08/11 08/29/11
Transfusion Blood/Blood Products (Spanish) 577092 11/12 11/21/12
Transjugular Intrahepatic Portosystemic Shunt (TIPS) (English) 577004 11/11 11/28/11
Transjugular Intrahepatic Portosystemic Shunt (TIPS) (Spanish) 577019 11/11 11/28/11
Transplant Consents:
Consent Addendum for Participation in KPD/NKR and Non-Directed and Bridge Donation 577515 11/17 11/29/17
Consent Addendum for Participation in KPD/NKR and Non-Directed and Bridge Donation (Spanish) 577515-SP 11/17 12/12/17
Deceased Donor Option Consent for Hepatitis C Liver 577512 11/17 11/29/17
Deceased Donor Option Consent for Hepatitis C Liver (Spanish) 577512-SP 11/17 12/12/17
Heart Transplant (English) 577010 09/18 11/29/18
Heart Transplant (Spanish) 577010-SP 09/18 11/29/18
Heart Transplant Recipient Informed Consent for Transplant Evaluation (English) 577048 11/18 11/29/18
Heart Transplant Recipient Informed Consent for Transplant Evaluation (Spanish) 577048-SP 11/18 11/29/18
Heart Transplant Recipient Informed Consent for Transplant Process (English) 577048-A 11/18 11/29/18
Heart Transplant Recipient Informed Consent for Transplant Process (Spanish) 577048-A-SP 11/18 11/29/18
Heart Transplant - Consent for Deceased Heart Donor Organ Options (English) 577052 09/18 11/29/18
Heart Transplant - Consent for Deceased Heart Donor Organ Options (Spanish) 577052-SP 09/18 11/29/18
Informed Consent for Living Kidney Donation 577513 11/17 11/29/17
Informed Consent for Living Kidney Donation (Spanish) 577513-SP 11/17 12/12/17
Informed Consent for Living Liver Donation 577514 11/17 11/29/17
Informed Consent for Living Liver Donation (Spanish) 577514-SP 11/17 12/12/17
Kidney Transplant - Consent for Deceased Kidney Donor Organ Options (English) 577068 06/19 07/12/19
Kidney Transplant - Consent for Deceased Kidney Donor Organ Options (Spanish) 577068-SP 11/14 12/03/14
Kidney Transplant - Consent for Transplant Evaluation Process 577126 03/12 04/13/12
Kidney Transplant - Living Kidney Donation (English) 577042 06/18 06/13/18
Kidney Transplant - Living Kidney Donation (Spanish) 577042-SP 06/18 06/19/18
Kidney Transplant - Recipient (English) 577192 11/14 12/03/14
Kidney Transplant - Recipient (Spanish) 577192-SP 11/14 12/03/14
Liver Transplant (English) 572112 05/18 06/13/18
Liver Transplant (Spanish) 572212-SP 05/18 06/19/18
Liver Transplant Program - Liver Allograft (English) 577054 05/18 06/13/18
Liver Transplant Program - Liver Allograft (Spanish) 577054-SP 05/18 06/19/18
Liver Transplant Program - Evaluation Process (English) 577056 11/14 04/07/15
Liver Transplant Program - Evaluation Process (Spanish) 577056-SP 11/14 04/07/15
Urine Drug Screening (English/Spanish) 577233 12/12 01/09/13
Uterine Artery Embolization for Fibroids (English) 577002 02/13 03/01/13
Uterine Artery Embolization for Fibroids (Spanish) 577029 04/13 04/29/13
Venous Access/Port (English) 577003 12/12 01/09/13
Venous Access/Port (Spanish) 577017 11/11 11/21/11
Wound Debridement 571638 11/12 11/08/12
Photography/Media
Consent to Photography (for purposes of treatment - English) 571940 01/08 01/18/11
Consent to Photography (for purposes of treatment - Spanish) 572140 01/11 01/17/11
Media Consent (English) 570631 05/11 05/06/11
Media Consent (Spanish) 570631-SP 05/11 05/06/11
Release of Medical Records
Authorization to Disclose Health Information (HHC) 571559 10/19 06/11/20
Authorization to Disclose Health Information (HHC) (Spanish) 571559-SP 10/19 06/11/20
Authorization to Disclose Health Information (IOL) (English) 573008 05/12 06/22/12
Authorization to Disclose Health Information (IOL) (Spanish) 571826 05/12 06/22/12


Miscellaneous Documents/Forms

Form Name HH-DPC# Rev. Posted
Diabetes Service Nurse Practitioner Follow-Up 572306 08/13 09/30/13
Hartford Hospital "DO NOT USE" Abbreviations n/a 12/03 11/24/10
Pain Treatment Center New Patient Consult n/a 05/14 05/08/14
Pain Treatment Center Progress Note n/a 05/14 05/08/14
Patient Guide to Surgery 570186 03/05 12/01/06
Patient Guide to Diabetes Medications Before Surgery (English) 571140 12/07 02/12/08
Patient Guide to Diabetes Medications Before Surgery (Spanish) 571140 12/07 02/12/08
Transplant Program Medication Renewal/Request List n/a n/a 01/06/11
Trauma Progress Note 571588 09/11 03/13/12
Trauma Supplemental Resuscitation Record 571138 11/11 03/13/12
Trauma Tertiary Survey 571916 10/11 03/13/12

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