important documents

Conditions of Registration and Consent (California Only)

1. Medical Treatment and Surgical Consent: I consent to the procedures that may be performed during this hospitalization or while I am an outpatient. These may include, but are not limited to, emergency treatment or services, laboratory procedures, x-ray examinations, medical or surgical treatment or procedures, telehealth, anesthesia, or medical center services provided to me under the general and special instructions of my physician or surgeon. I understand that the practice of medicine and surgery is not an exact science and that diagnosis and treatment may involve risks of injury, or even death. I acknowledge that no guarantees have been made to me as to the result of examination or treatment in this medical center.

2. Nursing Care: Nurses are hospital employees and they provide general nursing care and care ordered by the physician(s). If I want private duty nursing care, I (or my legal representative) agree to make such arrangements.

3. Legal Relationship between Medical Center and Physicians: Physicians and surgeons, including, but not limited to, radiologists, pathologists, emergency physicians, anesthesiologists, cardiologists, surgeons, hospitalists, and some nurse practitioners and physician assistants providing services to me are NOT employees of the medical center and have been granted the privilege of using the medical center for the care and treatment of their patients. Physicians may bill separately for their services. I understand that I am under the care and supervision of my attending physician. The medical center and its nursing staff are responsible to carry out his/her instructions. My physician or surgeon is responsible for obtaining my informed consent, when required, for specific medical or surgical treatment, special diagnostic or therapeutic procedures, or medical center services rendered to me under his/her general or special instructions. Notice to Consumer: physician assistants are licensed and regulated by the Physician Assistant Committee (916)-561-8780 Medical doctors are licensed and regulated by the Medical Board of California (800)-633-2322

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4. Photography: I consent to the taking of photographs, videotapes, digital or other images, and surveillance monitoring for purposes of my diagnosis, treatment, or for the medical center’s operations, including peer review, education or training programs conducted by the hospital. My consent will be requested for non-treatment photography such as marketing or external purposes.

5. Maternity Consent for Newborns: If I deliver an infant(s) while a patient of this hospital, I agree that these same Conditions of Registration shall apply to the newborn infant(s).

6. Personal Valuables: As a patient, I am encouraged to leave valuable personal items at home. While the medical center maintains a safe for small personal items of unusual value, it is not responsible for these items. Medical center liability for any personal property deposited with the hospital for safekeeping is limited. I understand that the medical center cannot assume liability for any personal items I choose to keep with me during my admission. I agree to the hospital staff conducting an inventory of my personal belongings in my presence. If any items of an illegal nature are found, I agree these should be removed or disposed of, and items may be provided to law enforcement authorities if necessary.

7. Teaching Program: If the medical conducts teaching programs, students will be allowed to participate in my care, unless I (or my legal representative) notify the medical center to the contrary in writing.

8. Nondiscrimination: I am informed that the medical center does not discriminate based on age, race, ethnicity, color, ancestry, religion, culture, language, physical or mental disabilities, socioeconomic status, sex, sexual orientation, and gender identity or expression. Additionally, I understand that room assignments are made based on gender identity.

9. Notice of Privacy Practices: I have received a copy of the Notice of Privacy Practices (NPP), which describes when the medical center may use or disclose my information for treatment, payment, and health care operations, my legal rights relating to this information and how I can file a complaint if I believe my rights have been violated. The NPP is incorporated into these Conditions of Registration and Financial Agreement by this reference. This notice is only provided the first time I receive services from the medical center and is otherwise available upon request.

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10. Financial Agreement: I accept financial responsibility for all services during this episode of care. I understand that I can expect to receive separate bills from physicians and specialty services. I agree to promptly pay all hospital bills in accordance with the regular rates and terms of the medical center and, if applicable, the medical center’s charity care and discount payment policies under state and federal law. Should the account be referred to an attorney or agency for collection, I will pay actual attorney’s fees and collection expenses. All delinquent accounts are subject to interest at the legal rate. I hereby authorize the medical center and/or its agent(s) to request credit information from various credit reporting bureaus for the collection of my account including, but not limited to, collection of delinquent accounts, the evaluation of requests for financial assistance, and routine credit scoring.

11. Consent to Telephone Calls for Financial Communications: If the telephone number I have provided to the medical center is a wireless telephone number, I hereby consent to receive auto-dialed and/or pre-recorded calls, including debt collection calls, from or on behalf of the medical center at this number in the course of routine business communications.

12. Assignment of Insurance Benefits: I assign and authorize direct payment to the medical center of all insurance and plan benefits that are payable for this episode of care. With this authorization, all parties agree that the insurance company’s payment to the medical center shall satisfy the insurance company’s obligation related to this episode of care. I further understand that I am financially responsible for charges not paid according to this assignment.

13. Financial Assistance: I have been informed of Adventist Health's Financial Assistance policy. I understand more information about the policy can be found at facility registration area(s), the website, by calling (844) 827.5047, or by writing Adventist Health ATTN: Financial Assistance PO Box 619122 Roseville, CA 95661.

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14. Medicare Assignment: I certify that the information given by me in applying for payment from any third party payer, including payments under Title XVIII of the Social Security Act, is correct. I request that payment of authorized benefits be made on my behalf, and I authorize the Social Security Administration Office of the Department of Health and Human Services to release information regarding my eligibility for coverage under Medicare Part A and Medicare Part B, including but not limited to the effective date of coverage. I also authorize the medical center and my physician(s) to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim(s).

15. Outpatient Medicare Patients: Medicare does not cover prescription drugs in an outpatient medical center setting with only a few exceptions. “Self-administered drugs” are drugs you would normally take on your own. I acknowledge that I am responsible for the payment of any drugs furnished to me while an outpatient that meets Medicare’s definition of a prescription drug. Medicare Part D beneficiaries may submit a paper claim to the Medicare Part D Plan for possible reimbursement of these drugs in accordance with Medicare Drug Plan enrollment materials.

16. Patient Self Determination Act: I have been furnished information regarding Advance Directives (such as durable power of attorney for health care and living wills). I have also been furnished with written information regarding patient rights and responsibilities and other information related to my stay. Please initial or place a mark next to one of the following:

□ I executed an advance directive and have been requested to supply a copy to the medical center.
□ I have not executed an advance directive, but I wish to execute one. I have received information on how to execute an advance directive and may require assistance with obtaining and/or completing an advance directive
□ I have not executed an advance directive and do not wish to execute one at this time.

I have been given the opportunity to read this document, ask questions and have been offered a copy of this consent.

Patient/Patient Representative Signature: X______________________________

Date: ________ Time: ________

Printed Name: _____________________________

□ I am the patient
□ I am the patient’s legal representative
□ I have been authorized by the patient to sign on the patient’s behalf

If you are not the patient, please identify your relationship to the patient.
□ Spouse
□ Parent
□ Legal Guardian
□ Healthcare Power of Attorney
□ Guarantor
□ Other (please specify) ________________________

Witness Signature and Title: (required for patients unable to sign or without a representative)

X ____________________________________

Date: ________ Time: ________

Printed Name: _____________________________

Interpreter Signature: __________________________________

Interpreter Printed Name: _______________________________

Language used for translation of document: ___________________________________

Date: ________ Time: ________