THIS PATIENT CONSENT AGREEMENT
The agreement applies to services provided by Community Health Network, Inc., Community Hospital North, Community Hospital East, Community Hospital South, Community Heart and Vascular Hospital (a facility of Community Hospital East), Community Howard Regional Health, Community Westview Hospital (a facility of Community Hospital East), Community Howard Specialty Hospital, Community Physician Network, Community Howard Physician Network, Community Home Health, Community Surgery Center North, Community Surgery Center East, Community Surgery Center South, Community Surgery Center Hamilton, Community Surgery Center Northwest, Community Surgery Center Howard, Community Endoscopy Center Indianapolis and Community Digestive Center Anderson (each of these health care providers whether individually licensed or operating under the license of another hereinafter referred to collectively as “Community”). This Patient Consent Agreement is valid for up to one year for all physician practice and outpatient services provided by Community.
I request or authorize Community to provide and perform under the direction of my physician(s) and/or his/her designee such care, procedures, services and supplies as are considered advisable for my health and wellbeing. I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me by my physician(s) or Community as to the result of any treatments, examinations, procedures or other services provided by Community. I authorize Community to dispose of any tissue, severed or amputated member, body part, or medical device removed in connection with services provided by Community. I understand that it is the responsibility of the physician to explain to me the nature of any diagnostic, therapeutic, medical and/or surgical procedures necessary to treat me and to explain risks and consequences associated with the services.
Patient Rights and Advance Directives
If I am receiving hospital inpatient services, ambulatory surgical center services or home health services, I acknowledge I have been given written materials on my patient rights and responsibilities, which include my right to an advance directive. For all other Community services, I understand that information about advance directives is available upon request.
Consent to Release Medical Records
I understand Community will make every effort to treat my medical record information as confidential; however, I realize information must be shared with other providers involved in my care or in the payment of my care. Further, I understand other healthcare providers involved in my care will have access to my medical information. I consent to the release of my medical information for treatment, payment and health care operational purposes as allowed by state and federal law, including the release of communicable disease information.
I understand my services may be provided by: (1) health care providers who are not employees of Community but who have a contract with Community to provide services, such as emergency physicians, anesthesiologists, radiologists, pathologists and other independent physicians; and (2) health care providers who have no employment or other contractual relationship with Community; and these providers may or may not participate in my insurance plan. I understand Community is responsible for carrying out the instructions of such providers, but I acknowledge (a) such providers are not employees or agents of Community; and (b) Community is not responsible for the medical decisions, acts or omissions of such providers.
Assignment of Insurance Benefits
I assign payment to: (1) Community; (2) health care providers who are not employees of Community, but who have a contract with Community to provide services, such as emergency physicians, anesthesiologists, radiologists, and pathologists; and (3) health care providers who have no employment or other contractual relationship with Community. I understand I will receive separate bills for services ordered or rendered by providers who are not employees of Community and who may or may not participate in my insurance plan. I understand Community verifies my benefits and/or bills my insurance company as a courtesy to me. I authorize Community to release to Medicare and its agents any information needed to determine my benefits for services received. I authorize the release of my medical records and any other information necessary to obtain payment from Medicare, Medicaid and other payers. I request that payment of authorized benefits from Medicare, Medicaid and other payers be made on my behalf to Community for services provided by Community. This assignment does not apply to patients with insurance that is not accepted by Community. Further, I understand that verification of my benefits is not a guarantee the insurance company will pay those benefits and I am responsible for ensuring that any prior authorization required for my services is obtained in advance of treatment. In addition, I hereby appoint Community and its employees and agents as my representative to #le grievances and appeals for me with my insurance plan/HMO as allowed by Indiana State law.
Responsibility for Payment
I understand that I may request and receive an estimate of anticipated charges. I understand and acknowledge that an estimate is not a guarantee; that the estimate is not binding upon Community; and that actual charges will be determined based on the services I receive and may be more or less than the estimate. I understand that I am financially responsible for all amounts not paid by insurance or other payers for services provided to me by Community and I agree to pay all charges when due or in accordance with any financial arrangement made at the time of discharge. I understand Community provides financial assistance in the form of reduced charges, payment options, and payment plans to those who qualify. I understand I can request additional information on payment options or financial assistance if I believe I may not be able to pay or may not be able to pay timely. In the event I do not pay such charges when due, I agree to pay costs of collection, including attorney fees and interest. I authorize Community or its agent to access my credit report in order to collect any charges due. If I provide Community with my cell phone number, I authorize Community or its agent to call my cell phone either manually or by auto-dialer in order to collect any amounts I owe.
Release of Responsibility for Valuables
I understand that Community is not liable for personal possessions including, but not limited to, money, valuables, dentures, eyeglasses, hearing aids or other property, that are lost or damaged. I know Community has the right to search anything on its premises, including wallets and purses, for the safety and welfare of its patients and visitors. I know I can avoid having my possessions searched by sending them home.
Receipt of Notice of Privacy Practices
I acknowledge that I have received the Community Health Network Notice of Privacy Practices and understand that I can also access a copy at www.eCommunity.com.
I acknowledge that I have read and agree to pages 1 and 2 of this Patient Consent Agreement and my questions have been answered. I understand that I can request a copy of this document.
Copyright © 2018 MDLIVE, Inc. All rights reserved. Copyright © 2018 MDLIVE Medical Group, PA. All rights reserved. MDLIVE Medical Group, PA provides the clinical services for MDLIVE. MDLIVE Medical Group, PA is an independent entity.