NAME:
DATE SIGNED:
1. CONSENT FOR MEDICAL/EMERGENCY TREATMENT: I hereby consent to and authorize St. Vincent's Health System to render usual and customary medical/emergency treatment, including drug and alcohol testing, diagnostic, radiological, and laboratory procedures, minor surgical procedures and administration of local anesthetics as necessary, and other general medical/emergency treatment and hospital care considered advisable or necessary by the physician.
2. PHYSICIANS: I understand that my doctor and other doctors who provide care to me while I am in the hospital (such as Emergency Department doctors, doctors who read X-rays and test specimens removed from me, and doctors and Certified Registered Nurse Anesthetists who give anesthesia) are not the agents, servants or employees of St. Vincent's Health System, but are individuals practicing independently at the hospital.
3. FINANCIAL AGREEMENT AND ASSIGNMENT OF INSURANCE BENEFITS: I hereby authorize payment directly to St. Vincent's Health System of the hospital insurance benefits otherwise payable to me but not to exceed the balance due of the hospital's regular charges for this period of hospitalization. I further assign the benefits payable for physician's services to the physician or organization furnishing the services. I understand I am financially responsible to
the hospital for charges not covered by this authorization payable within 30 days of treatment. I also agree to pay all costs of collections including reasonable attorney's fees.
4. AUTHORIZATION TO PAY MEDICARE BENEFITS TO PROVIDER: (Medicare patients only) I hereby certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for physician services to the physician or organization furnishing the services or authorize such physician or organization to submit a claim to Medicare for payment to me. I hereby acknowledge the above and agree to pay or cause to be paid any and all charges the Medicare/Medicaid program determines as not allowable and/or any Health Insurance deductibles and co-insurance amount. I have been offered the brochure "An Important Message from Medicare."
5. AUTHORIZATION FOR RELEASE OF INFORMATION: I hereby consent that St. Vincent's Health System may disclose my hospital records, including my Social Security number, to my hospital insurance companies, workmen's compensation carriers, my attending/referring physician, welfare agencies, Medicare and Medicaid or other governmental agency which is or may be liable for all or part of the hospital charge or which may assist in providing for my care.
6. SAFETY: For the safety of our patients, employees and visitors, possession or use of firearms, knives or other weapons is strictly prohibited within the hospital and hospital grounds. The possession or use of unauthorized controlled substances is also strictly prohibited within the hospital and hospital grounds. The undersigned acknowledges that St. Vincent's Health System reserves the right to search personal belongings of patients when St. Vincent's Health System believes that the patient may be in possession of an item or items dangerous to the health or safety of the patient or to others.
7. TRAINING: St. Vincent's Health System operates a Family Medicine Residency Program and participates in various training programs for healthcare providers. All care rendered by individuals must be supervised and reviewed by appropriate personnel. The undersigned hereby consents to the care and treatment of individuals in training.
8. CONSENT FOR TESTING: I hereby give St. Vincent's Health System my permission to test my blood for Hepatitis B Surface Antigen, Hepatitis C Antibody and for HIV (AIDS) virus antibodies if a healthcare worker has an accidental exposure to my blood or body fluids. I understand that this request is the usual procedure for following healthcare worker's exposure to blood or body fluids.
9. VALUABLES: I understand that St. Vincent's Health System is not responsible for money, jewelry, dentures, clothing, hearing aids, breathing devices, eyeglasses, wigs, credit cards, or other valuables kept in my room. Any and all valuables should be sent home. Valuables can be collected and stored for safe keeping in a secure location at the facility until needed at the time of discharge. I fully understand that I am responsible for the items I keep with me and release St. Vincent's Health System from any responsibility for these items.
10. ACKNOWLEDGEMENT OF PATIENT RIGHTS: I hereby acknowledge that by signing this CONSENT FOR TREATMENT, I have received a copy of the Patient Bill of Rights and am aware of my Patient Responsibilities and how to contact my Patient Representative, Alabama Quality Assurance Foundation and Joint Commission's Office of Quality
Monitoring. If presenting for a surgical procedure or admission I have received the Patient Information Booklet.
I acknowledge that I have read this form and understand its purpose and content. PATIENT OR RESPONSIBLE PARTY RELATIONSHIP TO PATIENT WITNESS
A COPY OF THIS FORM SHALL BE CONSIDERED AS EFFECTIVE AND VALID AS THE ORIGINAL.
