Consent for Treatment (PDF) - Memorial Hospital of South Bend

Patient IdentificationCONSENT FOR TREATMENT – Inpatient, OOS, ECC1. CONSENT FOR TREATMENT: I request and voluntarily give consent to my physician and other physicians,including medical residents, who may attend me during this present period of treatment, their associates and assistants,Memorial Hospital of South Bend and its agents and employees and students under the direction thereof, to provide andperform evaluation, treatment, consultation and/or other care, services and supplies as are considered advisable by myphysician for my health and well being. I recognize that certain physicians furnishing services may be independentcontractors and not employees or agents of Memorial Hospital of South Bend. I understand that services will be providedor supervised by appropriately credentialed staff within the scope of their license, certification and training. I acknowledgethat no representations, warranties or guarantees as to results or cures have been made to me.2. RELEASE OF INFORMATION FOR PAYMENT OF SERVICES AND CONTINUITY OF CARE: I understand thatMemorial Hospital and my physician(s) will release any and all information regarding diagnosis, treatment and prognosiswith respect to any physical or psychiatric condition-including treatment for alcohol or drug abuse-for which I am beingtreated at Memorial, To any insurance company, employer, school, sponsored payer and/or third party payers, orrepresentative providing coverage for this admission. Information will also be released to healthcare providers forcontinuity of care.I understand that federal law and regulations do not protect any information about a crime committed by a patient atMemorial Hospital or against any person who works for Memorial Hospital or about any threat to commit such a crime.Federal laws and regulations do not protect any information about suspected abuse or neglect from being reported understate law to appropriate state or local authorities.3. ASSIGNMENT OF BENEFITS: In consideration for services rendered or to be rendered to me by or throughMemorial Hospital, I hereby assign to Memorial Hospital all insurance benefits, including Medicare, covering this presentperiod of treatment. I understand that regardless of this assignment, I remain primarily responsible to Memorial Hospitalfor all actual charges related to this present period of treatment. It is further agreed that any self pay credit balanceresulting from payment of the insurance benefits may be applied to any other account owed to Memorial Hospital by me ormy family.4. FINANCIAL AGREEMENT: I will make every effort to actively assist Memorial Hospital with securing payment forservices rendered for which I am liable. If I am the parent/guardian of a minor patient, I understand that unless addressedin my third-party payer agreements, I am financially responsible for all services rendered, and that the parent whoauthorizes treatment will be responsible for any balance due. I understand that Memorial Hospital submits claims toinsurance carriers to assist its patients and that I am responsible for the balance owed at any time unless otherarrangements have been made.I understand that my third-party payer may require me to obtain prior/post-authorization in order to cover services. Iunderstand that if I do not provide sufficient and timely information and releases of information for Memorial Hospital toprocess insurance claims, I will be responsible to pay Memorial Hospital full and standard fees. I agree to pay anycollection costs and/or legal fees incurred by Memorial Hospital in attempts to collect the balance owed on my account.Consent to receiving auto-dialed and or artificial or pre-recorded message calls to me cellular or and line telephones.5. OUTSIDE SERVICE PROVIDERS: I understand that physician charges and professional fees for theinterpretation of diagnostic services may be billed separately. I give consent for Memorial Hospital to provide insuranceinformation to outside service providers so that they can bill for services. I understand that if I receive any physician’sservices or other services that are billed separately from Memorial Hospital this authorization will serve as a release ofinformation and assignment of benefits for these providers, and payment is to be made directly to them or their billingservices. I further understand that not all of the physicians and other healthcare providers who treat me are employees ofMemorial Hospital.Page 1 of 2Form 575509 7/93 718105 (Rev 3/2012)CONSENT FOR TREATMENT

Consent for Treatment , page 2Patient Identification6. PERSONAL VALUABLES AND PROPERTY DAMAGE: I understand that Memorial Hospital maintains a safe forthe safekeeping of money and valuables and shall not be liable for the loss or damage to any money, jewelry, documents,or other articles of unusual value, or any other personal property not placed in the safe,7. CONSENT TO PHOTOGRAPH: I consent to have my photograph taken and used for identification during mytreatment, and then maintained in my medical record, as requested by Memorial Hospital.8. WEAPONS/ CONTRABAND SEARCH: I understand that Memorial Hospital policy prohibits the introduction offirearms and weapons on Hospital property by other than Sworn Police Officers and Memorial Security Staff. Any weaponnow in my possession will immediately be removed for the Hospital or placed in the Hospital safe. I understand thatbased on certain criteria for the safety of all staff and patients, if I have certain conditions or behaviors I may have myperson and belongings searched.9. NOTICE OF PRIVACY PRACTICES AND ADVANCE DIRECTIVE NOTIFICATION: I acknowledge that I havereceived Memorial Hospital’s Notice of Privacy Practices currently or in the past and will advise hospital staff if this is notcorrect. Further, I understand that I must provide a copy of any advance directive in order for my wishes to be honored.10. AUTHORIZE OBTAINING HEALTH-RELATED INFORMATION: I authorize Memorial Hospital staff to obtain myhealth and prescription information from electronic sources, such as, SureScripts, or from my Physician’s office or otherappropriate sources which might be available.11 PRIVACY OR NON-PRIVACY PATIENT STATUS: As a patient of Memorial Hospital, relatives, friends, andothers may inquire about me and request information concerning my condition, visiting privileges, phone number, andrelated public information. Unless I check the NO box, Memorial Hospital my release public information to thoserequesting it, as permitted by law. Behavioral Health Patients will be privacy patients.No, you may NOT release PUBLIC INFORMATION to those requesting it.12. RELEASE OF SOCIAL SECURITY NUMBER FOR ANY IMPLANTED DEVICES: I authorize the release of mySocial Security Number to the manufacturer of any implanted medical devices I might receive, in accordance with federallaw and regulations. I understand that my Social Security number may be used by the manufacturer to help locate me ifthere is a need to contact me with regard to the medical device. I release Memorial from any liability that might result fromthe release of this information.13. RESPONSIBILITY IF LEAVING EARLY: I understand and agree that if I leave Memorial Hospital before mytest results are available and/or before my treatment is complete, that I will still have to pay for any tests or treatments Ireceived and that Memorial Hospital will not be responsible for my care. I will be responsible for my care.14. GOVERNING LAW AND VENUE: I understand that any claim or dispute arising from or related to the treatmentor services I receive will be determined according to Indiana law without regard for Indiana’s conflict of law rule and thatthe venue for any lawsuit will be in St. Joseph County, Indiana.15. I ACCEPT THE TERMS LISTED ON THIS DOCUMENT AND CERTIFY THAT A COPY OF THIS DOCUMENTHAS BEEN MADE AVAILABLE TO ME. I certify that I am the patient or am legally authorized to sign for the patient.SIGNATURE OF PATIENT OR LEGALLY AUTHORIZED REPRESENTATIVE DATE TIMEPRINTED NAME OF LEGALLY AUTHORIZED REPRESENTATIVE, IF NOT THE PATIENTRELATIONSHIP TO THE PATIENTSIGNATURE OF WITNESSPage 2 of 2Form 575509 7/93 718105 (Rev3/2012)Consent for Treatment