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Patient Consent to Treatment Admission Form

1. Consent to Medical and Surgical Procedures
The patient identified above, or his or her legal guardian consents to the procedures and treatment that may be performed during this hospitalization or on an outpatient basis, including emergency treatment or services, and which may include but are not limited to laboratory procedures, x-ray examinations, medical and surgical treatment or procedures, anesthesia, or hospital services rendered for the patient under the general and special instructions of the patient’s physician or other healthcare provider.

2. Nursing Care
The hospital provides only general duty nursing care unless, upon orders of the patient’s physicians, the patient is provided more intensive nursing care.

3. Legal relationships between Hospital and Physician
All physicians furnishing services to the patient, including those physicians who may be called upon to provide care either directly (as consultants) or indirectly through professional services (i.e. radiology, anesthesiology,
etc.) and including on call physicians are independent contractors with the patient and are not employees or agents of the hospital. The patient is under the care and supervision of his/her attending physician and it is the
responsibility of the Hospital and its nursing staff to carry out the instructions of such physician. The patient’s informed consent is required, to perform surgical treatments or special diagnostic or therapeutic procedures.

4. Acknowledgement of investors
Thereby acknowledge that I have been notified that this facility has physician investors. I acknowledge that I was made aware that I may request and obtain a listing of these physician investors.

5. Physician availability notice
The Atrium Medical Center is committed to providing its patients high quality medical care in a comprehensive and efficient manner. The Atrium Medical Center firmly believes that the quality of medical care is greatly
enhanced by ensuring the patients and the patient’s families are fully informed of the services offered by Atrium Medical Center. Considering the specialized nature of this facility, it is important that Atrium Medical
Center inform you, as a patient, that because full service emergency room services are not available at this facility, this facility does not offer the on-site availability of a physician 24 hours per day, 7 days per week. Thus,
in order to ensure the safety of our patients, Atrium Medical Center has put the following procedures in place to meet the needs of any patient who develops an emergency medical condition at a time when there is no
physician immediately present in the hospital.
1. A qualified RN will be immediately available to provide bedside care to any patient while at the
facility. A qualified RN will be immediately available to recognize and react to a person needing emergency care.
2. There is a RN who is qualified through education, license, and training immediately available to provide initial treatment.
3. When the person’s emergency exceed the hospital’s capabilities, the RN reacting to the emergency will assure appropriate handling of a transfer to an appropriate facility. The person’s necessary
medical records will be sent along with the patient being transferred.

6. Release of Information
The hospital may not release to the public any information about the patient, including name, city of residence, age, sex, the nature of patient’s injury or the patient’s general condition. If the patient’s legal representative wishes such information to be released, he/she must make a written request to the hospital for such information to be released. The patient or the patient’s legal representative may obtain a separate form for this purpose upon request. The undersigned agrees that the Hospital and/or physician may not disclose any portion of the patient’s record,
including his/her medical records (including psychiatric and/or drug and alcohol abuse information and the results of specific laboratory tests, including Patient Consent to Treatment Admission Form, AMC 2007 HIV or
AIDS diagnosis), to any person or entity that is or may be responsible for all or any portion of the Hospital’s and/or physicians’ charges, including but not limited to insurance companies, health care service plans,
worker’s compensation carrier, medical or utilization review organization designated by any of the foregoing, or to any other person or entity as necessary in connection with such payment or reimbursement without consent from the patient. The undersigned also agrees that the Hospital and/or physician may obtain from any source and examine, discuss and disclose my medical records and information, including medical history,
examinations, diagnosis; treatments and HIV or AIDS information to treating Hospital personnel and agents, other health care providers, medical researcher, medical record auditors, professional committees, care
evaluators and governmental agencies. This consent to release and obtain information is valid for a period of 90 days from the date of signing hereof provided, however, the undersigned may revoke this consent at any
time upon delivery of written instruction, except with regard to disclosures that have already been made in reliance on such consent.
The undersigned acknowledges that the hospital may transfer or assign to any person or entity the right of the Hospital to receive payment for services rendered to patient, and the undersigned authorizes the Hospital to
disclose the patient records, including his/her medical records to any person or entity that (a) has been granted a security interest, pledge, assignment, or other interests in or right to receive, possess or collect such
payments or otherwise provide administrative services to Hospital or any transferee/assignee thereof, (b) is otherwise an assignee or transferee with respect to payments due Hospital arising from/or created as a result
of services rendered patient, or (c) provides administrative or collection services to any such persons or entity with respect to payments due Hospital arising from/or created as a result of services rendered patient.
Please be aware that administrative data and other information describing patient care, services and outcomes are collected and used for the following purposes; quality management, performance improvement, governmental and non-governmental reporting, and comparisons of the Hospital with other health care providers. In some instances, performance data (such as length of stay) is aggregated and reported per physician. In every instance, the Hospital strives to maintain patient and physician anonymity. The Hospital has policies and procedures in place to maintain the confidentiality and privacy of patient information.

7. Photo/Audio/Video Release
The undersigned agrees to have his/her photograph taken, or to be videotaped or filmed, solely for the purpose of medical treatment. If the Hospital wishes to publish the resulting images in brochures, newsletters,
newspapers, and other printed matter, or to broadcast audio/video/film on television, radio, or for other uses, Hospital must obtain consent from the patient. If the patient or the patient’s legal representative does not wish
such information to be released, he/she must make a written request for such information to be withheld. The patient or the patient’s legal representative may obtain a separate form for this purpose upon request.

8. Personal Valuables
It is understood and agreed that the Hospital maintains a safe for safekeeping of money and valuables, and the Hospital shall not be liable for the loss of or damage to any money, jewelry, documents, furs, fur coats, and fur garments, hearing aids, dentures, or other articles of unusual value and/or small size, unless placed in the safe, and shall not be liable for
loss or damage to any other personal property, unless deposited with the Hospital for safekeeping. The maximum liability of the Hospital for loss of any personal property, which is deposited, with the Hospital for safekeeping is limited to five hundred dollars ($500.00) unless a written receipt for a greater amount has been obtained from the Hospital by the patient.

9. Financial Obligations
The undersigned agrees that, in return for the services to be rendered to the patient, the undersigned hereby individually obligates himself/herself to pay the account of the Hospital in accordance with the regular rates as charges by the charge master and terms of the Hospital. I understand that I am not relieved of responsibility for charges except as to amounts
actually received by Hospital or otherwise contractually specified. However, if the patient is eligible to receive benefits under a health care service plan, the patient shall not be obligated to pay off any services provided by the hospital that are covered under plan which are paid for by the health care service plan. If any excess funds remain after payment in full
of the charges for services rendered for this Hospital visit, the undersigned hereby authorizes the Hospital to apply such excess funds toward any non-covered services and/or other outstanding account(s) which the patient may have with Hospital for any prior services rendered to the patient and for which the undersigned is responsible. Should the patient’s
account become delinquent and be referred to an attorney or collection agency for collection, the undersigned shall pay actual attorney’s fees and collection expenses. All delinquent accounts may be charged interest at the maximum rate allowed by law. 1-I understand that I am financially responsible for my health insurance deductible, coinsurance or noncovered
service within 90 days of my discharge. 2-In the event that my health plan determines a service to be “not payable”, I will be responsible for the complete charge and agree to pay the costs of all services provided.

10. Assignment of Insurance or Health Plan Benefits to Hospital
The undersigned assigns and hereby authorizes, whether he/she signs as agent or as patient, direct payment to the Hospital of all insurance and health plan benefits otherwise payable to or on behalf of the patient for this
hospitalization or for outpatient services, including emergency services if rendered, at a rate not to exceed the Hospital’s regular charges. The undersigned, whether he/she signs as agent or as patient, assigns to the
Hospital any and all rights he or she may have against a health insurance plan relating to services provided at the Hospital, whether based on express or implied contract or upon statute, including but not limited to any
rights authorizing the collection of damages or penalties related to the insurance company’s failure to timely or expeditiously pay a claim as provided for health care services rendered. It is agreed that payment to the
Hospital pursuant to this authorization by an insurance company or health plan shall discharge said insurance company or health plan of any and all obligations under the policy to the extent of such payment. It Is
understood by the undersigned that he/she is financially responsible for charges not covered by this assignment.

11. Assignment of Insurance or Health Plan Benefits to Physicians
The undersigned authorizes, whether he/she signs as agent or as patient, direct payment to any physician of any insurance or health plan benefits otherwise payable to or on behalf of the patient for professional services
rendered during this hospitalization or for outpatient services, including emergency services if rendered, at a rate not to exceed such physician’s regular charges. It is agreed that payment to such physician pursuant to
this authorization by an insurance company or health plan shall discharge said insurance company or health plan of any and all obligations under the policy to the extent of such payment. It is understood by the
undersigned that he/she is financially responsible for charges not covered by this assignment.

12. Medicare Patients Release of Information
I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize the Hospital, any governmental agency, and any agent of any of the foregoing to release any information needed to act on this request or to verify my Medicare eligibility. I request that payment of authorized benefits be made in my behalf. I assign payment for the unpaid charges of the physician(s) for whom the Hospital is authorized to bill in connection with its services. I understand I am responsible for any remaining balance not covered by other insurance.

13. Mutual of Omaha/Medicare Notice
Medicare will not pay for private rooms unless medically justified, personal convenience items, diagnostic admissions for tests or hospital stays not medically necessary. My signature below acknowledges my receipt of
the information regarding mutual of Omaha/Medicare from the Hospital.

14. Advance Directive Acknowledgment Statement
I have been advised of the law and Hospital policy regarding Advanced Directives and Patient Rights and have been given information regarding this subject.
I have executed an Advanced Directive to Physicians

Advanced Directive YES

Advanced Directive NO

I have executed a

Medical Power of Attorney YES

Medical Power of Attorney NO

I have given my physician and/or the Hospital a copy I want to receive information about Advanced Directive

physician and/or the Hospital YES

physician and/or the Hospital NO

I have received the information on Advanced Directive.

information on Advanced Directive YES

information on Advanced Directive NO

I understand that my Advanced Directives will not be I have received and have read a copy of the Patient Rights and honored until I have given the appropriate documents Responsibilities Form.

Patient Rights YES

Patient Rights NO

15. Health Maintenance Organization (“HMO”) Acknowledgment
I have informed the Hospital if I am currently a

I have informed YES

I have informed NO

I may become an HMO member, either

I may become YES

I may become NO

Member of an HMO, Medicare, or otherwise Medicare or otherwise, during this Hospital stay.

16. Risk, Benefits, and Treatment Options
The risk, benefits, and treatment options have been explained to me in a language that I can understand.

Finance Responsibility Agreement by person other than the patient or the patient’s Legal
12. Medicare Patients Release of Information
I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is
correct. I authorize the Hospital, any governmental agency, and any agent of any of the foregoing to release
any information needed to act on this request or to verify my Medicare eligibility. I request that payment of

12. Medicare Patients Release of Information
I agree to accept financial responsibility for services rendered to the patient and to accept the terms of Financial
Obligations (Paragraph 9) and Assignment of Insurance or Health Plan Benefits (Paragraphs 10 and 11) as set forth above.

I certify that I have read the foregoing, received a copy thereof, have been given an opportunity to ask questions and am the patient, the patient’s legal representative, or am duly authorized by the patient’s general
agent to execute the above and accept its terms.

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October 4, 2023 5:10 pm CDT

Patient Consent to Treatment Admission Form Uploaded by Brent Kirkendall - esign@atriummedicalcenter.com IP 40.132.84.250