I. RELEASE OF INFORMATION for Treatment; Payment/Assignment of Benefits;
I understand and accept that Deborah Heart and Lung Center (DHLC) may use and disclose my protected health information to carry out treatment, payment, or health care operations and for other purposes consistent with the DHLC Notice of Privacy Practices.
I understand and accept that DHLC may disclose all or part of my medical record to approved DHLC Staff; other health care providers providing me with care and treatment (i.e., primary care physicians, consultants, auxiliaries); regulators and government agencies, entities performing services and functions for or on DHLC’s behalf, and to other individuals required or permitted by law, all as described in the DHLC Notice of Privacy Practices.
I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act or other provider(s) is correct.
In connection with the medical care provided to me at DHLC, except as otherwise prohibited by law, I understand and accept that DHLC, and any treating physician(s), may release my medical records (or other relevant information about me) to the Social Security Administration (its intermediaries, or carriers), Medicare, Medicaid and other payors or insurers as needed to receive payment for this (or a related) medical claim.
I authorize payment directly to Deborah Heart and Lung Center and the Professional Service Fund of Deborah, as applicable, for the benefits, medical, surgical or anesthesia which may otherwise be payable to me for the services described.
I hereby consent to the release of my name, address, and telephone number to DHLC’s designated polling service for the sole purpose of surveying me after my discharge regarding my care and treatment at DHLC.
II. ROUTINE EXAMINATION AND TREATMENT
Consent: I, the undersigned, requiring diagnosis, medical and/or surgical care, hereby consent to:
the performance of routine care such as diagnostic laboratory procedures and non-surgical treatment by Deborah Heart & Lung Center (DHLC) and its attending physicians and employees. This consent does not include surgical procedures, transfusion of blood or blood components, or any invasive procedures. At a later time, if such surgical or invasive procedures or transfusion of blood or blood components are required, I will be asked to give additional consent for them in advance, except in emergent situations.
the performance of non-invasive diagnostic procedures to include but not limited to: (CAT) scan, radiographic procedures; cardiologic procedures, electrophysiology or pacer procedures. Where leads are utilized, I understand there may be a minor skin reaction to the adhesive glue. Where a contrast agent is used, I understand that some patients may have a reaction to the contrast agent. This reaction may be mild like itching and hives and rarely, more severe, such as trouble breathing or anaphylactoid reaction. Occasionally decreased kidney function may occur as a result of a reaction, most often when there is pre-existing kidney disease. Rarely, leaking of contrast material from the vein into surrounding tissue may occur. I understand I have the right to ask to speak to a physician regarding the nature, purpose and risks of this procedure at any time prior to the procedure.
Medical Education: I understand that DHLC is a teaching facility. I am aware that among those who attend to my care are medical, nursing and other health care personnel in training who, unless I request otherwise, may participate in my care.
Risk: I understand that all medical care involves risk, and I acknowledge that no guarantees have been made regarding the results that can be expected from care provided at DHLC. I also acknowledge that I have the right to be informed of risks, benefits, and alternatives of each procedure, and any other information which I may need to know in order to give consent before care is provided. I also understand that I have the right to refuse consent to any proposed procedure or therapeutic course.
Recurring Visits: If the services I need require me to make multiple visits, my signature hereon shall be valid for care rendered throughout those visits. If during this period, any of my registration information changes, (i.e. address, phone, employment, insurance, guarantor, etc.), I will provide notification and documentation of change to DHLC.
III. ADVANCE DIRECTIVE
I acknowledge that I have received Advance Directive information. I understand that I have the right to execute an Advance Directive at any time, and that I may revoke a previously provided Advanced Directive at any time. I understand that an Advance Directive if given will only be used if I am unable to make decisions on my own.
I understand that photographs, videotapes, digital or other images may be recorded to document my care or for education and training purposes by DHLC, and I hereby consent to this. I understand that I have the right to request the cessation of the recording or filming and that I have the right to rescind this consent for use up until a reasonable time before recording or filming begins. I understand that DHLC will retain the ownership right to these photographs, videotapes, digital or other images. I understand that these images will be stored in a secure manner that will protect my privacy and that they will be kept for the time period required by law or outlined by DHLC’s policy. Images that identify me will be released/or used outside of the institution only upon written authorization from me or my legal representative except as otherwise may be described by DHLC’s Notice of Privacy Practices.
V. FOUNDATION BUSINESS
I hereby consent to be asked to participate in a personal interview by an authorized representative(s) of the Deborah Hospital Foundation for the purposes of the Foundation and DHLC Business and health care practices. I understand I am not obligated to participate in such personal interviews.
VI. PERSONAL PROPERTY
I understand that DHLC has the ability to and has provided me with the opportunity to safeguard my patient valuables within the Department of Security. I acknowledge and agree that DHLC is not liable for loss or damage of personal property unless deposited for safekeeping with DHLC. I accept full responsibility for all articles and valuables kept in my possession.
I acknowledge that I have received the handout entitled: “Handout: Conditions of Service and Patient Acknowledgment, Medicare Information, Patient Rights, Notice of Privacy Practices” with the following:
Copy of Conditions of Service and Patient Acknowledgment
Notice to Patients About the Use of Medicare Information
Notice of Your Patient Responsibilities and Bill of Rights as a Patient at Deborah Heart and Lung Center
Notice of Privacy Practices
VIII. CONSENT AND ACKNOWLEDGMENT
I have read this TWO-PAGE form (including reverse side of this page) and have had all of my questions answered. I acknowledge I have received a copy of and understand this Conditions of Service Consent Form, and hereby certify and agree to all its terms. (A COPY OF THIS AUTHORIZATION SHALL BE AS VALID AS THE ORIGINAL).
I acknowledge I have received a copy of and understand the Deborah Heart and Lung Center Notice of Privacy Practices. I hereby acknowledge and approve of the uses and disclosures of my protected health information consistent with such Notice of Privacy