Consent for Treatment (PDF) - Memorial Hospital of South Bend

Consent for Treatment , page 2Patient Identification6. PERSONAL VALUABLES AND PROPERTY DAMAGE: I understand that Memorial Hospital maintains a safe forthe safekeeping of money and valuables and shall not be liable for the loss or damage to any money, jewelry, documents,or other articles of unusual value, or any other personal property not placed in the safe,7. CONSENT TO PHOTOGRAPH: I consent to have my photograph taken and used for identification during mytreatment, and then maintained in my medical record, as requested by Memorial Hospital.8. WEAPONS/ CONTRABAND SEARCH: I understand that Memorial Hospital policy prohibits the introduction offirearms and weapons on Hospital property by other than Sworn Police Officers and Memorial Security Staff. Any weaponnow in my possession will immediately be removed for the Hospital or placed in the Hospital safe. I understand thatbased on certain criteria for the safety of all staff and patients, if I have certain conditions or behaviors I may have myperson and belongings searched.9. NOTICE OF PRIVACY PRACTICES AND ADVANCE DIRECTIVE NOTIFICATION: I acknowledge that I havereceived Memorial Hospital’s Notice of Privacy Practices currently or in the past and will advise hospital staff if this is notcorrect. Further, I understand that I must provide a copy of any advance directive in order for my wishes to be honored.10. AUTHORIZE OBTAINING HEALTH-RELATED INFORMATION: I authorize Memorial Hospital staff to obtain myhealth and prescription information from electronic sources, such as, SureScripts, or from my Physician’s office or otherappropriate sources which might be available.11 PRIVACY OR NON-PRIVACY PATIENT STATUS: As a patient of Memorial Hospital, relatives, friends, andothers may inquire about me and request information concerning my condition, visiting privileges, phone number, andrelated public information. Unless I check the NO box, Memorial Hospital my release public information to thoserequesting it, as permitted by law. Behavioral Health Patients will be privacy patients.No, you may NOT release PUBLIC INFORMATION to those requesting it.12. RELEASE OF SOCIAL SECURITY NUMBER FOR ANY IMPLANTED DEVICES: I authorize the release of mySocial Security Number to the manufacturer of any implanted medical devices I might receive, in accordance with federallaw and regulations. I understand that my Social Security number may be used by the manufacturer to help locate me ifthere is a need to contact me with regard to the medical device. I release Memorial from any liability that might result fromthe release of this information.13. RESPONSIBILITY IF LEAVING EARLY: I understand and agree that if I leave Memorial Hospital before mytest results are available and/or before my treatment is complete, that I will still have to pay for any tests or treatments Ireceived and that Memorial Hospital will not be responsible for my care. I will be responsible for my care.14. GOVERNING LAW AND VENUE: I understand that any claim or dispute arising from or related to the treatmentor services I receive will be determined according to Indiana law without regard for Indiana’s conflict of law rule and thatthe venue for any lawsuit will be in St. Joseph County, Indiana.15. I ACCEPT THE TERMS LISTED ON THIS DOCUMENT AND CERTIFY THAT A COPY OF THIS DOCUMENTHAS BEEN MADE AVAILABLE TO ME. I certify that I am the patient or am legally authorized to sign for the patient.SIGNATURE OF PATIENT OR LEGALLY AUTHORIZED REPRESENTATIVE DATE TIMEPRINTED NAME OF LEGALLY AUTHORIZED REPRESENTATIVE, IF NOT THE PATIENTRELATIONSHIP TO THE PATIENTSIGNATURE OF WITNESSPage 2 of 2Form 575509 7/93 718105 (Rev3/2012)Consent for Treatment