Healthcare Hospital Tower Form

HEALTHCARE HOSPITAL TOWER ADMISSION & CONSENT FORM

Patient Information

Patient Name:

Emergency Contact

Admission Details

Admission Date:   Time:

Insurance Information

Medical History

Chronic Conditions (check all that apply):

Advance Directives

Do you have an advance directive, living will, or healthcare proxy? Yes No

Consent for Treatment — Hospital Tower Services

I authorize Healthcare Hospital Tower personnel and the attending physicians to provide or arrange for medical care, diagnostic tests, procedures, medications and/or surgical treatment as necessary for the patient named above. I understand that no specific promise or guarantee has been made as to the results of any treatment.

Risks and benefits: I acknowledge that the nature, risks, benefits and alternatives of the proposed care or procedures have been explained to me in terms I understand. I recognize that there are inherent risks, including but not limited to infection, bleeding, allergic reaction, organ injury, need for further procedures, and death depending on the intervention. I have had an opportunity to ask questions and these questions have been answered to my satisfaction.

Right to withdraw: I understand that I may refuse or withdraw consent to the proposed treatment at any time prior to its initiation, except in those situations where immediate treatment is required by law or where withdrawal would create unreasonable risk. Withdrawal of consent will be documented and discussed with the care team.

Financial Responsibility & Facility Policies

I accept financial responsibility for charges not covered by insurance and understand that payment policies apply. I authorize release of medical information to my insurer as necessary for claims processing. I acknowledge that the hospital has policies regarding visitation, infection control, visitor screening, and use of mobile devices which I agree to follow while on the premises.

HIPAA — Privacy & Authorization to Disclose

I acknowledge receipt of the facility's Notice of Privacy Practices and understand that my protected health information may be used and disclosed for treatment, payment, and healthcare operations as described therein. I authorize the hospital to disclose my protected health information to the persons named below and for the purposes stated.

This authorization will remain in effect until the expiration date specified above or until revoked in writing by the patient, except to the extent that action has already been taken in reliance on this authorization. I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected.

Facility Safety & Visitor Policy Acknowledgment

I have been informed of and agree to comply with Healthcare Hospital Tower safety, visitor, and infection prevention policies, including screening, hand hygiene, and mask use when requested. I understand the hospital may restrict visitors when clinically appropriate.

Certification & Signature

By signing below I certify that the information I have provided is true and complete to the best of my knowledge. I consent to the care and treatment described above and accept financial responsibility as stated. I understand that this form does not guarantee specific outcomes.

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