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Treatment Authorization and Acknowledgement

Geary Community Hospital, including its Acute care, Swing bed unit, Rehab unit, Senior Health, Emergency department, Outpatient surgery and outpatient departments is hereinafter referred to as “Hospital."

  1. CONSENT FOR TREATMENT. Consent to x-ray examinations, laboratory procedures, anesthesia, medical or surgical treatment, hospital services, and/or other services rendered under the general and special instructions of my attending or consulting physicians. I understand that my treatment is under the control of my attending physicians, their assistants, or designees. If admitted, I understand that if I desire private duty nursing care, it is agreed that such must be arranged by myself or my family and the Hospital shall be released from any and all liability arising from such care. I understand that if further diagnostic studies or treatment procedures that are considered major in nature, such as an operation, are required, I will be asked to give specific consent for these prior to them being carried out. I understand that the practice of medicine and surgery is not an exact science, and acknowledge that no guarantees have been made to me as to results of care, treatment, and the provision of medical services.
  2. CONSENT FOR NEWBORN TREATMENT. Request, authorize, and empower my physician(s) to make any provision for medical and surgical care for my newborn baby / babies that may be deemed necessary or advisable by my physician(s).
  3. CONSENT FOR BLOOD / BODY FLUID TESTING. In the event that a health care worker or emergency response person(s) is suspected to have had exposure to my blood and/or body fluids or if it is likely that a health care worker or emergency response person(s) is exposed to my blood and/or body fluids, due to my illness or an uncommon rare disease, I consent to have the Hospital determine by serological testing whether or not my blood contained contagious viruses. I understand that the information obtained from such tests will only be disclosed as necessary to adequately protect my own health and the health of my family, as well as the health of those health care personnel or emergency response person(s) who may have been or become involved in my treatment.
  4. CONSENT TO DISPOSAL OF TISSUE / FLUIDS / SPECIMENS. I agree that the Hospital may utilize, destroy, or dispose of any tissues, fluids, or specimens taken from me during treatment.
  5. PHOTOGRAPHY AND OTHER IMAGING. I understand that photographs, videotapes, digital, or other images may be recorded to document my care, and I consent to this. I understand that the hospital will retain 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 in the hospital’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.
  6. AGREEMENT TO PAY FOR SERVICES. I agree, whether I sign this as an agent or as the patient, that in consideration of services to be rendered to me, I hereby individually obligate myself to pay the charges of the Hospital in accordance with its regular rates and terms. However, I am aware that any patient arriving at the facility will have a medical screening examination performed regardless of the ability to pay.
  7. ASSIGNMENT OF INSURANCE BENEFITS. I hereby assign my insurance benefits otherwise payable to me to be paid directly to the Hospital. I understand that I am financially responsible for charges not covered by this assignment and further agree to guarantee full payment of all charges not covered by third-party payers. If I do not pay the amount due as I agreed, I agree also to pay the reasonable costs of collection, including but not limited to attorney fees and collection agency fee.
  8. MEDICARE / MEDICAID BENEFITS. I authorize the Hospital to release to Medicare and/or Medicaid, to the Social Security Administration and or its intermediaries or carriers, and to any peer review organizations, any information needed for this or a related Medicare and/or Medicaid claim. I request payment of authorized benefits to be made on my behalf to the Hospital for services furnished to me, and to the physicians involved for their services, including those physicians / specialists doing their own billing while I was a patient in the Hospital.
  9. PERSONAL VALUABLES / BELONGINGS. I understand that the Hospital CANNOT AND WILL NOT accept responsibility for the loss of any of my valuables/belongings, if they are lost or misplaced. I understand that I am, at all times, responsible for the safekeeping of my personal belongings. Dentures, glasses, hearing aids, medications, my garments and essential daily necessities are considered personal belongings.
  10. NOTIFICATION TO PATIENTS. Certain diseases and conditions, including cancer, are required by law to be reported. I understand that the Hospital will comply with this by submitting the necessary information on my condition and myself to a centralized registration point.
  11. CONTRABAND WEAPONS. I agree that should the Hospital find contraband weapons within my possession, these items will be confiscated and the police will be contacted.
  12. USE OF APPLIANCES. The Hospital has the right to inspect all outside appliances to assure safety for the Hospital. I hereby agree that in using any and all electrical appliances in my room, not owned by or under the control of the Hospital while a patient in the Hospital, I do so at my own risk and hereby absolve the Hospital from any and all responsibility for injuries or property damage which may result from any use of said appliance.
  13. PROVIDER NON-DISCRIMINATION ACT. I understand that this is an equal opportunity institution. There is no discrimination because of race, color, religion, natural origin, age, sex, handicap, or inability to pay.
  14. MEDICARE / TRICARE PATIENTS ONLY (Only for Acute Care). I have received a copy of “An Important Message from Medicare / Tricare” and I understand my rights as described in that document.
  15. PATIENT RIGHTS INFORMATION. I have reviewed / received “A Patient Rights and Responsibilities” and understand my rights as described in that document.
  16. NOTICE. Your health information related to work-related illnesses or injuries or to medical surveillance of the workplace may be disclosed to your employer.
  17. TOBACCO FREE CAMPUS. The use of tobacco products is prohibited: This includes within any GCH building, including open-air courtyards or gardens; On all property maintained by GCH, whether leased or owned, including all parking lots; to include The Home Care Bldg and Geary Rehab. In all vehicles owned, leased, or rented by GCH; In all vehicles when parked on GCH property. No tobacco sales or distribution of tobacco products will be allowed on GCH properties. Littering of tobacco related or any other products is prohibited on all GCH properties. Communication of this policy will be with signage on the GCH campus, written or verbal notices upon admission and assessment processes, and verbal reminders from hospital staff when necessary.

I certify that I have read and fully understand this document and that I have received a copy of it. I, as the patient / authorized agent, agree to sign this document indicating that I agree with all of its terms and statements.