| 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 |
| Acute Mechanical Circulatory Support Devices |
577248 |
06/23 |
12/21/23 |
| 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 |
| 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 |
| 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 |
R1-2024 |
03/08/24 |
| Left Ventricular Assist Device Insertion for Long-Term Circulatory Support |
577165-A |
R1-2024 |
03/08/24 |
| 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 |
| Bloodless Medicine Consents: |
|
|
|
| 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 |
| Refusal of Blood and Blood Derivatives (FOR REVIEW ONLY) |
577734 |
09/21 |
04/07/22 |
| 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 |
07/23 |
08/03/23 |
| Heart Transplant (English) |
577010 |
03/21 |
08/03/23 |
| Heart Transplant Recipient Informed Consent for Transplant Evaluation (English) |
577048 |
11/18 |
08/03/23 |
| Heart Transplant Recipient Informed Consent for Transplant Evaluation (Spanish) |
577048-SP |
11/18 |
08/03/23 |
| Heart Transplant Recipient Informed Consent for Transplant Process (English) |
577048-A |
11/18 |
08/03/23 |
| Heart Transplant Recipient Informed Consent for Transplant Process (Spanish) |
577048-A-SP |
11/18 |
08/03/23 |
| Heart Transplant - Consent for Deceased Heart Donor Organ Options (English) |
577052 |
05/23 |
08/03/23 |
| 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 - 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 |
03/21 |
08/03/23 |
| Liver Transplant (English) |
572112 |
03/21 |
10/08/21 |
| 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 |
01/23 |
08/03/23 |
| Liver Transplant Program - Evaluation Process (Spanish) |
577056-SP |
01/23 |
08/03/23 |
| Liver Transplant Program - Evaluation Process (EXTENDED) (English) |
577056-EX |
07/23 |
08/03/23 |
| 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 |
11/22 |
12/13/22 |
| 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 |