Healthcare Admissions Agreement

HEALTHCARE ADMISSIONS AGREEMENT

Facility Name:    Facility Address:

Patient Information

Date of Birth:    Gender:

Phone:    Email:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy Number:    Group Number:

Medical History

Admission Details

Admission Date:    Admitting Diagnosis:

Attending Physician:    Level of Care:

Consent for Treatment and Authorization

By signing this Admissions Agreement, I hereby authorize the Facility, its employees and agents to provide medical and ancillary care as reasonably necessary for my diagnosis and treatment. I accept that clinical decisions will be made by licensed practitioners in accordance with applicable standards of care. I understand that no guarantee has been made as to the results of treatment.

Consent to Treat: I authorize treatment, procedures and diagnostic tests as ordered by my physician and consent to necessary routine care during my stay.

Financial Responsibility and Assignment

Financial Responsibility: The undersigned agrees to be financially responsible for charges not covered by insurance and accepts facility billing and collection policies.

Assignment of Benefits: I assign benefits payable from insurance, Medicare, Medicaid or other third-party payors to the Facility and authorize release of medical information necessary for claims processing.

Relationship to Patient:

Advance Directives and Preferences

Advance Directive on File: Yes    If yes, location of document:

Privacy and Release for Billing

HIPAA Acknowledgment: I acknowledge receipt of the Facility's Notice of Privacy Practices and consent to the use and disclosure of my protected health information for treatment, payment and health care operations as described therein.

Release for Billing: I authorize the Facility to release medical information to health plans and other entities as necessary for billing and payment of claims.

Facility Policies and Acknowledgments

I acknowledge that I have been provided with or offered access to the Facility's admission policies, visitor rules, safety protocols and grievance procedures. I accept responsibility to follow these policies while on Facility premises.

Acknowledgement of Policies: I acknowledge receipt of facility policies.

Representations, Limitations and Dispute Resolution

The undersigned represents that the information provided in this Admissions Agreement is true and complete to the best of their knowledge. The Facility will rely on the representations contained herein for admission, treatment and billing. The Facility is not responsible for loss or damage to personal property unless otherwise agreed in writing.

Dispute Resolution: Any dispute arising out of or relating to this Agreement will be resolved in accordance with procedures set forth in Facility policy and applicable law. This clause does not waive statutory rights where waiver is prohibited.

Additional Instructions / Special Needs

Patient Certification

By signing below, I certify that I have read and understand this Admissions Agreement, that I have had the opportunity to ask questions and receive answers, and that I consent to admission, treatment and the financial terms set forth above. I further certify that I am the patient or am authorized to sign on behalf of the patient.

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