Volunteer Handbook - Roper St. Francis Healthcare

Employee Health DepartmentPhone (843) 724-2131 - Fax (843) 724-1325Volunteer Information RecordVolunteer Name: First MI LastHome Address: StreetCityState Zip Home Phone Work PhoneAge Date of Birth Social Security NumberGeneral InformationReason for this visitPPDBlood WorkImmunizationsOther _______________Medical InformationAre you currently under a physician's care for any medical problems? No Yes: Please specify______________________________________________________________________Do you have allergies to drugs or to food? No Yes: Please specify______________________________________________________________________Personal Medical Provider:Name ________________________________________________Phone Number _______________________Emergency Contact:Name ___________________________Relationship _______________Phone Number _______________________I hereby voluntarily request, authorize and consent to medical care, diagnostic procedures and medical treatments as deemedappropriate by and delivered by RSFHC medical providers, related to the health problem(s) for which I have sought the services ofRSFHC. I further consent to have all relevant results and records of these diagnostic procedures and treatment forwarded to RSFHC. Ifurther authorize RSFHC to obtain my medical records, x-ray reports, physical therapy reports, laboratory reports, or other healthrelated information deemed necessary to allow the RSFHC medical provider to appropriately diagnose and/or treat my medicalcondition(s) and/or assess my ability to work. I further authorize RSFHC to release information contained in my RSFHC Medical recordnecessary for review for Workers Compensation directly to RSFHC and assign to them insurance benefits otherwise payable to me.I understand that I am financially responsible to RSFHC for charges not covered by the employer. In so doing, I hold harmless RSFHCand its medical care providers from any liability regarding the release of information to RSFHC, the Insurance company for saidcompany, the cost containment company for said company or carrier, or any other party as required by law. A photocopy or facsimilecopy of this release is effective as an original document.Volunteer Signature___________________________________________________________ Date ____/____/______S:\volunteer\Application Handouts\Application - EHO Form.doc