I am presenting myself for admission to the hospital, outpatient procedures or telehealth services. I voluntarily consent to the rendering of medical care which is determined to be necessary or beneficial in the professional judgment of my physician. This includes routine diagnostic procedures and medical treatment by authorized agents and employees of the Hospital, and by its medical staff or their designees. I acknowledge that no guarantees have been made to me as to the effect of such examination or treatment on my condition.
I understand it is customary, absent emergency or extraordinary circumstances, that no substantial procedures are to be performed upon a patient unless and until he or she has had an opportunity to discuss them with the physician to the patient’s satisfaction, and that each patient has the right to consent, or to refuse consent to any procedure or therapeutic course.
I understand that many of the physicians on the staff of this hospital, including the attending physician(s) are not employees or agents of the hospital, but rather, are independent contractors who have been granted the privilege of using its facilities for the care and treatment of their patients.
RELEASE OF RESPONSIBILITY
I understand that the hospital assumes no responsibility for cash, jewels, or personal electrical devices that I may choose to keep in my room. I understand that these may be deposited with the hospital for safekeeping and that the use of electrical devices is discouraged within the hospital.
UNIFORM ASSIGNMENT AND RELEASE OF INFORMATION AUTHORIZATION
Authorization for release of information:
I hereby authorize and direct the CLARINDA REGIONAL HEALTH CENTER and physicians, having treated me, to release to governmental agencies, insurance carriers, or others who are financially liable for my hospitalization and medical care, all information needed to substantiate payment for such hospitalization and medical care, and to permit representatives thereof to examine and make copies of all records relating to such care and treatment. I hereby authorize and direct the Clarinda Regional Health Center to release information (as the provider deems necessary) to any current providers of care, including the primary care physician. Authorization will expire at the conclusion of one (1) year from the date of signature. All patient health information, including mental health records, are stored within the electronic health record of Clarinda Regional Health Center.
Assignment:
I hereby assign, transfer, and set over to the CRHC and treating physicians sufficient monies and/or benefits to which I may be entitled from government agencies, insurance carriers, or others who are financially liable for my hospitalization and medical care to cover the costs of the care and treatment rendered to myself or my dependent in said medical facility. It is understood this release does not relieve me of financial liability. I hereby authorize CRHC to contact me via phone, email or text message and that I may receive e-surveys regarding my care.
While the CRHC Emergency Department (ED) always remains open, it does not have a physician on the premises 24/7 but is covered with 24/7 "on-call" physicians. Each month the medical staff establishes a rotation schedule. Physicians are required to respond to calls from the ED in a reasonable time. Response times are monitored. Physicians are obligated to provide inpatient care to any patient seen at the ED while on-call if the patient is admitted to CRHC. This obligation continues until the patient is properly discharged.
Photography:
I understand that photographs, videotapes, digital, or other images may be recorded for identification purposes, or to document my care, and/or treatment, and I consent to this. I understand that Clarinda Regional Health Center will retain the ownership rights to these photographs, videotapes, digital, or other images, but that I will be allowed access to view them or obtain copies. 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 Clarinda Regional Health Center's policy. Images that identify me will be released and/or used outside the institution only upon written authorization from me or my legal representative. I understand that taping procedures can interfere with treatment and I am not allowed to tape or otherwise record in any treatment or recovery area.
Notice of Privacy Practices (NPP):
I acknowledge that I received the September 23, 2013 NPP.
The undersigned has read the above consent, authorizations, and releases, and understands the same.