BATH COMMUNITY HOSPITAL-OUTPATIENT/ER

CONDITIONS OF ADMISSION AND/OR TREATMENT

 

MEDICAL AND SURGICAL CONSENT:  I hereby request and authorize treatment for this patient until such is revoked by me in writing.  I voluntarily consent to the rendering of such care including but not limited to IP admission, Out-Patient diagnostic procedures, and medical treatments, photos obtained related to my care, by authorized agents and employees of the hospital, and its medical staff or their designee, as may in their professional judgment be deemed medically necessary.  I am aware that the practice of medicine and surgery is not an exact science.  I understand and acknowledge that no guarantees can be made to me as a result of examinations, diagnostic testing, treatments, surgery or anesthesia. I also give my permission for Bath Community Hospital or Bath Physicians Group to check SureScript for prescription dispensing accuracy.

ACKNOWLEDGEMENT OF DEEMED CONSENT FOR HIV BLOOD TESTING – OR HEPATITIS B OR C VIRUSES

A law was enacted in Virginia in 1989, which authorizes health care providers to test their patients for HIV antibodies for Hepatitis B or C viruses when the health care provider is exposed to the body fluids of a patient in a manner which may transmit human immunodeficiency virus (HIV) or Hepatitis B or C viruses. Pursuant to this law, in the event of such an exposure, you will be deemed to have consented to such testing and to have consented to the release of the test results to the health care provider who may have been exposed.  However, you would be informed before any of your blood would be tested for HIV antibodies or Hepatitis B or C viruses pursuant to this provision, the testing would be explained, and you would be given the opportunity to ask any questions you might have.  Patients who test positive will also be afforded the opportunity for individual face-to-face disclosure of test results and appropriate counseling.

 

ASSIGNMENT OF INSURANCE BENEFITS:  I hereby assign unto Bath Community Hospital and its hospital-based physicians any and all hospital or medical benefits of any type arising out of any policy of insurance insuring patient or any other liable party to patient, said benefits are hereby assigned to hospital for application to patient’s account, and it is agreed that the hospital may receipt any such payment and such payment shall discharge the said insurance company or any and all obligations under the policy to the extent of such payment, the undersigned and/or patient being responsible for charges not covered by the assignment.

 

FINANCIAL AGREEMENT AND PAYMENT GUARANTEE:  Both the undersigned patient and the guarantor(s) agree that in consideration of the services to be rendered to the patient, they hereby individually obligate themselves to pay the charges of the hospital in accordance with the regular rates and terms of the hospital.  Should the account be referred to an attorney for collection, the undersigned shall pay reasonable attorney’s fees and collection expenses.  All delinquent accounts bear interest at the legal rate.

 

FOR MEDICARE/MEDICAID BENEFICIARIES ONLY:  I certify that the information given by me in applying for payment under Titles XVIII and XIX under the Social Security Act is correct.  I request that payment of authorized benefits be made on my behalf for any services furnished me by, or in, Bath Community Hospital, including physician services.  I authorize any holder of medical or other information about me to release to the Center for Medicare and Medicaid Services and their agents, any information necessary to determine these benefits or related services.

 

PERSONAL VALUABLES:     All patients are encouraged not to bring money or articles of value to the hospital, but in circumstances they do, all efforts will be taken to send those articles home with family/caregiver.  Valuables deposited with the hospital will need to be inventoried and receipted. Bath Community Hospital will not assume liability for money or articles of value should they be lost or become missing

 

 BCH PATIENTS RIGHTS:    I HAVE RECEIVED AND BEEN INFORMED OF BATH COMMUNITY HOSPITAL’S PATIENT RIGHTS.  A full version of these rights is available at registration.  I have also been given the opportunity to ask questions about the document.

 

RELEASE OF INFORMATION:  I further authorize the hospital or my physicians to release to my attorney, third-party agency, or any insurance company any information required in connection with payment for or medical necessity of this admission or visit.  I also authorize BCH or their departments to release my records for quality measures and/or peer review.  All possible protected health information will be de-identified.

 

NOTICE OF PRIVACY PRACTICES: I HAVE RECEIVED AND BEEN INFORMED OF BATH COMMUNITY HOSPITAL’S REVISED OCT 2013 PRIVACY NOTICE.  A full version of this document is available at registration.  I have also been given the opportunity to ask questions about the document.

 

COLLECTION OF AMOUNT OWED: You agree, in order for us to service our account or to collect any amounts you may owe, we may contact you by telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or e-mails, using any e-mail address you provide to us.  Methods of contact may include using prerecorded/artificial voice message and/or use of an automatic dialing device, as applicable.  I/We have read this disclosure and agree that the Lender/Creditor may contact me/us as described above.

 

PATIENT SAFETY:

 

Do you have concerns about your safety in your environment?

________YES       _______NO

Are you concerned about harming yourself or others?

________YES      _______NO

 

Have you traveled outside the country/USA in the last 3 weeks?

________YES       _______NO

 

Location:__________________________

 

________________________________________           ___________________________________

Patient Signature                                                              Witness

 

_________________________________________           ____________________________________

Patient Agent or Representative Signature                        Relationship to Patient

 

_________________________________________

Date/Time Signed

 

AUTHORIZATION MUST BE SIGNED BY THE PATIENT OR BY THE NEAREST RELATIVE IN THE CASE OF A MINOR, OR WHEN PATIENT IS PHYSICALLY OR MENTALLY INCOMPETENT.