Several other health care providers in the area, including our organization use the same Excellian electronic medical record system to document and review the health care services they provide to you. Use of the Excellian electronic medical record allows your providers to coordinate your care, improve exchange of important information about your treatment, get complete and up-to-date information to any provider who uses Excellian.

A list of the healthcare provider organizations that currently use the Excellian electronic medical records system has been given for you to review with this consent. In the future, more health care providers may join in using this same
electronic medical record system. This consent applies to your providers who use the system now and in the future. You can review an up to date list of the providers who use this record system any time you come to Riverwood Healthcare Center for a visit or go to the Excellian website at www.Allina.com/medicalrecords for more information.

Your health information will be stored, viewed and shared by your health care providers in a secure electronic medical record system. When you are treated by any of the health care providers on this list, each provider will use the same electronic medical record to document information about your treatment. All of the information about your treatment with these providers will be combined into one electronic medical record that will be shared by all of them for your treatment. Once your information is combined, it cannot be separated.

I authorize any health care provider who uses the Excellian electronic medical record system to share the health records my providers create or receive related to my treatment, with other health care providers who treat me. My providers may share this information with each other as needed to provide my treatment and carry out services and operations related to my treatment. I understand that this information will be shared primarily through a combined electronic medical record where all of the health care providers who use Excellian and provide treatment to me will document my care and services.

This consent applies to health records that my health care providers already have about me, and information about future care I may receive from them. This consent will continue forever unless I cancel it by giving written notice to:
Riverwood Health Information Management, 200 Bunker Hill Drive, Aitkin, MN 56431. If I cancel the consent, it will apply to information created after the date when the notice to cancel is received. It will notaffect information that has already been shared among my health care providers or combined based on this consent.

I authorize my health care providers to share my records as described in this consent.

1. Provider Record Locator: A health record locator service helps my health care providers determine where I have received care and obtain information about my health to helptreat me. Riverwood Healthcare Center (RHCC) may access my information in a record locator service to help provide care to me. RHCC may share my health record and information with a healthrecord locator service unless I check the box below.

2. Release of Information By RHCC for Payment and Healthcare Operations: I consent to the release of my health records and other information related to my health care services for payment and healthcare operations purposes. I agree that my health records and other information may be released to Medicare, my insurance company or health maintenance organization, other payers, other providers involved in my care, payer network organizations, including accountable care organizations, in which my providers participate, and the contractors and third party administrators of any of these parties.

3. Release of Information by Others for Payment and Healthcare Operations: I authorize Medicare, my insurance company or health maintenance organization, other payers, payer network organizations including accountable care organizations, and their contractors and third party administrators to share my health records and information obtained from RHCC or any other provider, with RHCC, other providers from whom I have received services, or any other payer, payer network organization, including accountable care organizations, in which my provider participates, and the contractors and third party administrators of these parties as needed for payment and health care operations.

4. Release of Information to Health Care Providers: I consent to the release of my health records created, received and maintained by RHCC for my treatment to other health care providers who are involved in my treatment. This consent does NOT include release of information obtained by or created in a drug or alcohol abuse treatment unit.

5. Consent for Use of Medical Records in Research: I authorize RHCC to use or disclose my medical records for research, including health records created by RHCC and those records RHCC receives from other health care providers while treating me, unless I check here.

This consent will continue forever unless you cancel it by writing us at: Riverwood Health Information Management, 200 Bunker Hill Dr., Aitkin, MN 56431; but if the consent is cancelled, it will not change releases that have already been made.

Consent for Care: I am presenting myself for admission to the outpatient care at Riverwood Healthcare Center (hereunder referred to as RHCC) and I voluntarily consent to the rendering of such care, including diagnostic procedures and medical treatment by authorized agents and employees of RHCC, by its medical staffor their designee, as may in their professional judgment be deemed necessary or beneficial. I acknowledge that no guarantees have been made as to the effect of such examinations or treatment on my condition. I consent to the presence of students, consultants, and appropriate staff during all tests, examinations, medical treatment and other services provided to me at the hospital. I consent to photographs for the use of providing my care. I understand that while receiving care, accidental exposure to my blood or other blood fluids may occur. If this rare event occurs, I understand that my blood will be tested for the presence of Bloodborne Pathogens (Hepatitis B, Hepatitis C, and Human Immunodeficiency Virus). These tests are necessary to help protect and counsel the exposed individual. I understand that results of the tests will not be a part of my medical record and will not be released except with my prior consent or as required or permitted by law.
Assignment of Benefits: I request payment of authorized benefits directly to theprovider for services furnished to me at this facility or any other facility owned or operated by RHCC, including physician services, or by any provider under contract with RHCC or participating in a provider network in which
RHCC or its affiliates participate. Important Information for Patients: I acknowledge the following materials are available to me: Notice of Privacy Practices, Patient Bill or Rights, and Important Message from Medicare. Medicare Observation Patients Only: I am aware that an observation bed is reimbursed under Part B of the Medicare program and I will be responsible for any deductible and coinsurance assigned to the payment.

Guarantee and Agreement to Pay
NOTICE: Emergency patients are entitled to receive a medical screening examination and the necessary stabilizing treatment even if the patient (or responsible person) does not sign below. agree to pay the charges for the care and treatment rendered to me not covered by my insurance plan, or in the absence of insurance coverage (or, if signed by someone other than the patient, to guarantee payment for the care and treatment rendered to the patient named on this document). I understand that payment is due upon receipt of billing. Accounts are considered past due after 30 days from receipt of billing. If the account is referred to an attorney or collection agency, the patient will pay an additional 30% attorney’s fees and collection expenses.

To provide you with timely and relevant information, Riverwood Healthcare Center may contact you by telephone at any telephone number associated with your account, including mobile telephone numbers. We may also contact you by sending text messages or emails, using non-work email address you provide to us. Methods of contact may include pre-recorded voice messages and/or use of an automatic dialing device, as applicable. The types of messages we may communicate with you using the above methods could include:

· Appointment reminders

· Prescription notifications

· Pre-registration instructions

· Post-hospital/care instructions

· Billing and payment follow-up (including third-party collections)

· General health reminders/information

·  Obtain feedback on your experience

By signing below, I attest that I understand and accept each of the following: 

Costs. Standard text message and minute usage rates from my mobile or internet service provider may apply.

Privacy and Security. Receiving voice, email, and text messages from Riverwood Healthcare Center may impact the privacy and security of protected health information (PHI). Voice, email, and text messages are not encrypted. Information in voice, email, or text messages may not be secure.

Revocation. This consent to receive text messages or pre-recorded voice messages and/or use of an automatic dialing device on my mobile phone will be in effect until I have notified Riverwood Healthcare Center that I have revoked my consent by contacting (218)927-2157, or any other reasonable means of notifying Riverwood Healthcare Center that I revoke my consent.

Number Change. I will let Riverwood Healthcare Center know if my mobile phone number changes.