Conditions of Admission and Consent to Treatment

  1. CONSENT TO TREATMENT. I hereby request and consent to routine clinical, emergency hospital and medical care for the patient (and the patient’s newborn child in maternity cases) including all routine examinations, tests including HIV testing as described below, photographs and other procedures. Any tissue removed may be disposed of in Sidney Regional Medical Center (SRMC)’s customary manner. I acknowledge that no guarantees have been made as to the results of such clinical, hospital and medical care. I understand a patient has the right to refuse treatment and that my signature below is not consent to any special medical or surgical procedure. In the event that such procedures are recommended, it is the physician’s responsibility to explain the nature of the procedure, the reason it is recommended and the risks associated with the procedure. The physician and/or member of the nursing staff may ask the patient to sign a form confirming consent to the recommended procedure and alternatives to the procedure. Patients are encouraged to insist on any additional information necessary to make an informed decision to consent to or refuse treatment. No patient will be involved in any research or experimental procedure without his or her full knowledge and consent.
  2. CONTINUING OUTPATIENT CARE.  In some cases, proper treatment of a medical condition requires treatment or diagnosis over a course of repeated outpatient visits. In such cases, the request, consent, and agreements contained here shall apply to all repeat visits and all continuing treatment and diagnosis for the same condition.
  3. ASSIGNMENT OF INSURANCE BENEFITS. I hereby assign to SRMC, for services provided by SRMC and Physicians Clinics and their employees and others working under contract or arrangement with SRMC, all coverage or other benefits available under any government program, insurance policy or plan, or any other benefits program, and I direct that all benefits be paid directly to SRMC.  I agree that SRMC may receive benefits directly, which will discharge the insurer or benefit program to the extent of such payments. Any credit balance resulting from benefit payments or other sources may be applied to another account owed by the patient. This may not be revoked as to services provided during this hospitalization clinic visit, or corresponding course of diagnosis and treatment.
  4. FINANCIAL AGREEMENT. I agree to pay promptly and fully all charges for services and supplies provided by SRMC, physicians and other health care providers, in accordance with their regular rates and terms. I hereby personally obligate the patient and myself, if signing as a spouse of the patient or as parent or legal guardian of a minor patient, to pay all such charges to the extent not covered by insurance. No extension or forbearance, attempt to obtain payment from insurance or other sources, or delay or lack of diligence in collecting such charges shall waive or release this personal financial. I understand that it is my responsibility to obtain any pre-admission approval required by my insurer, and to take all other steps to qualify for insurance coverage.
  5. AUTOMATED TEXT APPOINTMENT REMINDERS. By signing below, the patient consents to the receipt of automated appointed reminders.
  6. AUTHORIZATION for RELEASE of  INFORMATION. By signing below, the patient authorizes SRMC to release all or any part of his or her medical records or such other information as may be necessary to process his or her claim for payment of benefits to insurance carriers and/or their representatives, his or her employer when services are related to a workers' compensation claim, the Social Security Administration or its intermediaries or carrier, and such other agencies, organizations, or individuals as necessary for a purpose related to benefit payment. By signing below, the patient authorizes SRMC to release all or part of his or her medical record from this visit to any physician or other health care provider (and their staff) who as necessary to aid in the continued care of the patient. If the patient does not want information sent, the patient should contact the Medical Records Department. The patient further understands that this consent applies to treatment yet to be provided. The patient acknowledges that such care will result in information being made a part of their medical record and that SRMC is under no obligation to consult further with the patient prior to disclosing such information pursuant to this authorization and their current insurance policy requirements for payment.
  7. INDEPENDENT PROFESSIONAL CARE. I understand that some of the physicians and certain other practitioners providing services to the patient may be independent contractors and not employees or agents of SRMC, and that SRMC is not responsible for the acts or omissions of such persons. I understand that if I desire private duty nursing or other health care services beyond those services normally provided at the SRMC, I will be responsible for arranging and paying for such services, and I must obtain SRMC approval of such private arrangements.
  8. BLOOD TESTS.  As a condition of admission, but ONLY in the event of direct exposure with the patient's blood or bodily fluids by a health care worker, I understand that SRMC must evaluate whether the worker has been exposed to any infectious diseases, and may draw patient’s blood for the purpose of performing, at SRMC’s expense, tests for infectious diseases such as the AIDS virus and hepatitis as SRMC deems necessary and appropriate for the protection of SRMC’s employees and staff. To preserve the patient’s confidentiality, the results of such a test performed pursuant to this authorization will be disclosed only to those with a need to know.
  9. NON-DISCRIMATORY.  In accordance with Section 1557 of the Affordable Care Act, Sidney Regional Medical Center does not discriminate on the basis of race, color, religion, national origin, sex (including gender identity), sexual orientation, age, or disability.

This consent shall remain in effect until the listed patient is 19 years of age or until I provide written notification to no longer be the guarantor for the accounts of this patient.

I have read and agree to the terms and conditions of the Admission and Consent to Treatment.*

 

Notarization: On this ______day of ___________, 20___, the said _________________________________

Is known to me (or satisfactorily proven) to be the person named in the foregoing instrument, and acknowledged that they freely and voluntarily executed the same for the purposes stated therein. I hereunto set my hand and official seal.

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Notary Public