Healthcare Stay Request

HEALTHCARE STAY REQUEST

Patient Information

Date of Birth:

Requested Stay Details

Requested Admission Date:

Expected Discharge Date:

Inpatient Observation Rehabilitation/Skilled Nursing Respite Same-day procedure

Insurance and Billing

Insurance authorization on file: Yes No

Medical History

Consent, Authorization and Administrative Notices

By submitting this Healthcare Stay Request, Patient Name: requests admission to the named facility and authorizes clinicians, allied health staff and authorized agents to perform assessments, diagnostic procedures, treatment, medication administration, transfer and other services necessary for medically indicated care during the requested stay. This authorization includes administration of anesthesia and procedures recommended by the attending physician when applicable.

Patient agrees that the facility may release medical records and information necessary for treatment, payment and healthcare operations to payers, other providers involved in care, and persons legally authorized to receive such information. Patient authorizes release of records to the insurer named above for claims processing and prior authorization as required.

Financial Responsibility: Patient (or responsible party) accepts financial responsibility for charges not covered by insurance, including deductibles, co-payments and non-covered services. Estimates provided are not guarantees of payment. Patient agrees that final billing and any collections for unpaid balances will follow facility policy.

Right to Withdraw: Patient may withdraw this request or any consent in writing; however, withdrawal will not affect care already rendered or obligations incurred prior to receipt of the withdrawal. Bed assignment and admission are subject to clinical review and bed availability; this request does not guarantee admission.

Emergency and Safety: If a medical emergency arises during the course of the request process or stay, the facility will initiate emergency care and transfer as indicated. Patient consents to such emergency measures where necessary to preserve life or prevent serious harm.

This authorization is valid until:

HIPAA / Privacy Acknowledgment: I acknowledge that I have been offered the facility's Notice of Privacy Practices describing how my protected health information may be used and disclosed, and my rights with respect to that information.

I acknowledge receipt of the Notice of Privacy Practices.

Representative / Guardian (if applicable)

By signing below, the signer certifies that they are authorized to request admission and consent to treatment for the patient, and that all information provided on this request is true and complete to the best of their knowledge. Intentional misrepresentation of facts may result in denial of admission and potential financial and legal liability.

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