Patient Welcome Book - Harrington Memorial Hospital

EALTH CARE PROXY FORM — page 1 of 2
__________________________________________________________(the principal),
________________________________, __________________ County, Massachusetts,
husetts General Laws Chapter 201D, appoint the following person to be my Health Care
_________________________ Phone #: ___________________________________
_____________________ City/State/Zip: ___________________________________
gent named above is not available, I name as an alternate Health Care Agent:
_________________________ Phone #: ___________________________________
_____________________ City/State/Zip: ___________________________________
are Agent authority to make all health care decisions on my behalf if I become incapable
General Information
isions for myself, including but not limited to decisions concerning initiation, continuing,
using any life-prolonging care, treatment, service or procedure, EXCEPT (here list the
, you wish to place on your Agent's authority):
Your personal physician, who is a member of Harrington’s medical staff, has
____________________________________________________________________
made all arrangements for your admission. Your physician’s office will advise you
of your exact admitting time. Please be sure to arrive at the Hospital on time.
____________________________________________________________________
Your pre-admission information is usually completed during your pre-admission
interview with Patient Registration. The form is mailed to maternity patients
____________________________________________________________________
before admittance. If you are admitted through to the emergency room, your
____________________________________________________________________
primary care physician, or the physician on call, will be notified of your admission
to Harrington Hospital.
____________________________________________________________________
Please present your health insurance identification card at the time of admission.
ent shall make Most insurance health care companies decisions have for restrictions me in accordance which require with notification my Health and Care approval Agent's
ishes, including before admission. my religious If you and are moral presently beliefs. employed, If my check wishes with are the unknown, Personnel my Health
ake such decisions
Department
for
at
me
your
only
place
in accordance
of employment.
with
If
my
necessary,
Health
bring
Care
any
Agent's
appropriate
assessment
forms,
of
properly signed and completed, to Patient Registration when you enter the Hospital.
Acceptance of gratuities tips by employees from patients, or their friends, is
ain any and all medical information, including confidential medical information, as I
prohibited. Please do not offer money or gifts to Hospital personnel.
receive. Photocopies of this Health Care Proxy shall have the same force and effect as the
given to other We welcome health your care suggestions, providers. comments and safety concerns. You may be contacted
and asked to complete a survey, or you can contact the CEO’s Office at the hospital,
nt's authority 100 South to act Street, on my Southbridge, behalf shall MA, exist or only call 508-765-9771. for the period You during may also which e-mail my us attending
s that I lack comments@harringtonhospital.org.
capacity to make or communicate health care decisions for myself
h Care Proxy Any concern ________________, or complaint should 20_____ be brought in the to the presence immediate of two attention witnesses. of the
appropriate nurse manager or department head, and, if the resolution is not
satisfactory, to the Hospital’s President & CEO. Should you or your family
____________________________________________________
members experience concerns about the care you are receiving, and a manager
is not available, please feel free to contact the on-duty nurse supervisor. You may
not sign) The call the principal nurse supervisor unable during to sign your and hospitalization at the direction by dialing of the zero principal for the I have signed
/her presence operator and in and the asking presence the hospital of two operator witnesses. to have a nurse supervisor call your
room. Your concerns are important to us in our effort to constantly provide
________________________________________________________________
quality patient care.
_______________________ City/Town: ______________________________
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1
Patient
Registration
Insurance
Gratuities
Surveys and
Patient Satisfaction
Concerns
During Your
Hospitalization