Outpatient Consent Form

HACKENSACK UNIVERSITY MEDICAL CENTER OUTPATIENT CONSENT FORM

1. CONSENT TO CARE: I wish to be treated by and/or admitted to Hackensack University Medical Center. While I am a patient, I give permission to my doctor(s), the hospital employees, and all the persons caring for me to provide care in ways they judge are beneficial to me. I understand that this care may include tests, examinations and medical treatments. I understand that the Medical Center is a teaching hospital and that under the appropriate supervision medical students, fellows and residents of the University of Medicine and Dentistry of New Jersey, Hackensack University Medical Center, or other teaching affiliates may participate in my care and treatment but I may decline such participation. I understand that no guarantees have been made to me about the outcome of this case. I hereby authorize Hackensack University Medical Center to preserve and use for scientific and/or teaching purposes, or dispose of any specimens or tissues taken from my body during hospitalization and hereby waive any claim or right I may have in such specimens or tissues.

2. INDEPENDENT PHYSICIANS: I understand and agree that the physicians who participate in my care and treatment at Hackensack University Medical Center are independent contractors or private practitioners and are not the agent or employee of Hackensack University Medical Center. I understand that the Medical Center is not responsible for the judgment or conduct of any physicians providing medical services at the hospital.

3. PATIENT RIGHTS: I acknowledge that I have received a copy of the New Jersey Patient Bill of Rights and an Advance Directive Brochure.

ADVANCED DIRECTIVE: Federal and State law require hospitals to ask the following questions of all adult patients being registered to their facility.

Do you have an Advance Directive or Living Will for healthcare? Yes No N/A

Name of Healthcare Proxy (If Applicable)

Was a copy of the document provided at the time of registration? Yes No

4. RELEASE OF INFORMATION: The Medical Center may see, release to and/or confirm, all or part of any financial and medical information, including information regarding psychological, psychiatric, HIV and related diagnosis, drug and/or alcohol related illness, with any person, corporation or government agency that is or may be responsible to the hospital, the patient, and family member or employer for all or part of the Medical Center’s charges or verification of the same.

5. PRE-CERTIFICATION REQUIREMENTS: I understand that if I do not comply with my insurance policy pre-certification requirements or if any admission is not certified, I will be responsible for any and all hospital charges.

Please check the appropriate box: (Pre-Certification)

I acknowledge that the pre-certification requirements I am responsible for have all been met. Yes No N/A

6. ASSIGNMENT OF BENEFITS: I authorize my health insurance benefits to be paid directly to Hackensack University Medical Center.

7. FINANCIAL AGREEMENT: When billed, I agree to make prompt payment to Hackensack University Medical Center for any and all charges not paid by insurance benefits, to the fullest extent permitted by law.

8. DEPOSIT REQUEST: A deposit has been requested of me because I will be paying for all and/or part of the hospital bill.

9. NEW JERSEY HOSPITAL CARE ASSISTANCE PROGRAM: I have received a copy of the notice of New Jersey hospital care assistance program.

10. MEDICARE PAYMENT REQUEST: I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct.

11. OUTPATIENT SERVICE “MEDICAID”: I certify that services covered by this claim have been received and I request that payment for these services be made on my behalf.

I have read the information contained above, any question I had have been answered, and I understand its contents. I attest that my personal information provided to Hackensack University Medical Center is correct.

I understand that this form will be valid for the period of one year from the date signed for all outpatient services. I also understand that I have the right to ask questions at any time regarding my treatment, care or any terms contained on this consent. If I wish to revise my consent, I may do so by completing a new form or if I wish to withdraw my consent, I must do so in writing.