• Shalom Health Care Center

    PROVIDING QUALITY HEALTH CARE THAT IS PATIENT-CENTERED, AFFORDABLE, AND ACCESSIBLE FOR ALL IN OUR COMMUNITY.
    Shalom Health Care Center
  • Shalom Health Care Center

    Shalom Health Care Center

    PROVIDING QUALITY HEALTH CARE THAT IS PATIENT-CENTERED, AFFORDABLE, AND ACCESSIBLE FOR ALL IN OUR COMMUNITY.
  • ADVANCE DIRECTIVE ACKNOWLEDGEMENT FORM
     
    An Advance Directive is a legal document allowing a person to give directions about future medical care or to designate another person(s) to make medical decisions if he or she should lose decision making capacity.
    1. You have the right to give written directions about future treatment before you become seriously ill or unable to make healthcare decisions. This is called an “Advance Directive”
    2. You have the right to accept or refuse medical or surgical treatment.
    3. An employee of the SHCC Patient Registration Department will provide you with information to help you develop an Advance Directive regarding your healthcare. You are not required to make any Advance Directive about your future medical treatment. This practice is completely voluntary. It is entirely your choice
    4. You may consult your doctor, family, lawyer, or others before making a written Advance Directive.
    5. If you decide to make an Advance Directive about future medical care it will become a part of your medical record at SHCC. Photocopies of your fully executed and witnessed directive should be made for your personal records, your family members and your proxy and alternate if you have chosen them. The original or a copy should be furnished to your hospital of choice whenever you receive inpatient care.
    6. You may revoke your Advance Directive at any time, in writing or simply by telling your attending physician or other healthcare provider or a witness, regardless of your physical or mental condition.
       
    I understand my rights as set forth above. Please check one of the following statements:
  • Note: It is the patient’s responsibility to provide SHCC with a copy of any Advance Directive document
    (living will, health care proxy, or medical power of attorney) or other document that could affect your
    care, if such document(s) exist.

  • Patient Name:   *   Patient Account No.   *   
    Signature:   *   Date:   Pick a Date*   

  • Patient Name:   
    Patient Account No.    
    Signature:    
    Date: Pick a Date   

  • The Center receives federal funding from Department of Health and Human Services (HHS) and has Federal Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.

    The Center receives federal funding from Department of Health and Human Services (HHS) and has Federal Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.

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