Healthcare Hospital Day Agreement

HEALTHCARE HOSPITAL DAY AGREEMENT

Patient Name:    Medical Record No.:

Date of Birth:    Gender: Male Female Other

Admission and Service Details

Date of Admission (anticipated):    Attending Physician:

Estimated length of stay (hours):

Medical History

Insurance and Financial Responsibility

Estimated charges for day services (non-binding estimate): $

Consent for Care and Treatment

I authorize the attending physician, consultants, nursing staff, and other hospital personnel to provide day admission care, diagnostic testing, medical or surgical procedures, administration of medications, intravenous fluids and routine anesthesia as indicated. I understand and consent to the following specific items as applicable (select all that apply):

Consent to day admission, nursing care, diagnostic testing, and routine treatment

Consent to anesthesia or sedation as required for the procedure

Consent to blood transfusion or blood products when medically necessary

Consent to clinical photography or video for medical records, treatment, or education (identifiers removed unless otherwise indicated)

The nature, purpose, benefits, material risks, and alternatives relevant to the proposed procedure or treatment have been explained to me, including the possibility of unforeseen complications. I acknowledge that no guarantee has been made as to the results or outcome of any treatment or procedure.

I understand that I may refuse or withdraw consent at any time prior to the procedure, and that withdrawal of consent may affect the timing or availability of services. If I withdraw consent during a procedure, I authorize the treating clinicians to take necessary actions to protect my health and safety.

Authorization to Release Information and Assignment

I authorize the hospital and its agents to release medical and billing information to my insurer(s) and other authorized third parties for the purpose of processing claims, obtaining payment, and coordinating care. I assign to the hospital any insurance benefits payable for services rendered and authorize payment to the hospital. I accept financial responsibility for charges not covered by insurance, including co-payments, deductibles, and non-covered services.

This authorization remains in effect until: or until revoked in writing as provided below.

HIPAA and Privacy Acknowledgement

I acknowledge that I have received or been offered the facility's Notice of Privacy Practices describing how my protected health information may be used and disclosed. I understand my rights under privacy law, including the right to request restrictions and confidential communications.

I acknowledge receipt of the facility's Notice of Privacy Practices

Patient Certification

By signing below I certify that I am the patient or legally authorized representative, that I have read and fully understand this Hospital Day Agreement, that the information I have provided is true and accurate to the best of my knowledge, and that I authorize the persons and institutions named herein to provide care and to release information as stated. I understand the financial obligations stated in this agreement and agree to pay amounts not covered by insurance.

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