New Port Richey Conditions of Admission

Date:December 5, 1995
Pages:1

1. MEDICAL AND SURGICAL CONSENT: The patient's care is under the control of his attending physicians and the Hospital is not liable for any act or omission in following the instructions of said physicians, and the undersigned consents to any x-ray examination, laboratory procedure, anesthesia, medical or surgical treatment or hospital services rendered the patient under the general and special instructions of the physician. The undersigned recognizes that all physicians furnishing services to the patient, including the Radiologist, Pathologist, Anesthesiologist, Emergency Department Physicians and the like may be independent contractors and are not employees nor agents of the Hospital.

RELEASE OF INFORMATION: I authorize HCA New Port Richey Hospital to release any pertinent information concerning my case history, examinations, treatments, etc., including copies of my medical records (not to exclude psychiatric and/or psychological information) to any legitimate requestors for filing of insurance claims. I hereby release the above named hospital from any legal liability that may arise from the release of the information requested.

3. PERSONAL VALUABLES: It is understood and agreed that the Hospital maintains a safe for the safekeeping of money and valuables and that the Hospital shall not be liable for the loss or damage to any money, jewelry, glasses, dentures, documents or other articles of value, unless deposited with the Hospital for safekeeping.

4. FINANCIAL AGREEMENT: The undersigned agrees, whether he signs as agent or as patient, that in consideration of the services to be rendered to the patient, he hereby individually obligates himself to pay the account of the Hospital in accordance with the regular rates and terms of the Hospital. Should the account be referred to an attorney for collection, the undersigned shall pay reasonable attorney's fees and collection expenses. All delinquent accounts bear interest at the legal rate.

5. ASSIGNMENT OF INSURANCE BENEFITS: In the event the undersigned is entitled to hospital benefits of any type whatsoever arising out of any policy of insurance insuring patient or any other party liable to patient, such benefits are hereby assigned to HCA New Port Richey Hospital and physicians rendering service to the patient, for application on patient's bill, and it is agreed that the Hospital may receipt for any such payment and such payment shall discharge the said insurance company of any and all obligations under the policy to the extent of such payment, the undersigned and/or patient responsible for charges not covered by this assignment.

6. STUDENT CARE RELEASE: I understand that there may be Allied Health Students participating in my care. These students are under the supervision of their instructors and/or the Hospital's professional staff. These students are affiliated with the local Community College and/or County Vocational Training Agencies, and are not considered as employees of this hospital.

7. TO: MEDICARE BENEFICIARIES:

This is to inform you that the care and services you will receive during your hospital stay, are subject to professional medical review. Federal Law P.L. 97-248 requires that Institutional care provided through Medicare, Medicaid, and Maternal and Child Health programs be reviewed on a continuing basis to ensure that you the patient receive adequate and appropriate health care services. In order to meet these requirements for medical care review, the Professional Foundation for Health Care, Inc. (PRO) collects and maintains information on these types and extent of health care services received by patients of this hospital.

The Professional Foundation for Health Care, Inc. (PRO) recognizes that medical information is private and therefore has established policies and procedures to ensure the confidentiality of patent information collected and maintained for purposes of professional medical review of hospital care and services.

ASSIGNMENT OF MEDICARE BENEFITS: PATIENT CERTIFICATION
AUTHORIZATION TO RELEASE INFORMATION AND PAYMENT REQUEST

A. "I certify that the Information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign the beneft payable for pnysician services or authorize such physician or organization to submit a claim to Medicare for payment to me. I understand that I am responsible for Part A deductible for each spell of illness, the Part B deductible for each year, the remaining 20% of reasonable charges and any personal charges incurred."

B. ACKNOWLEDGEMENT OF MEDICARE: I hereby declare I am a participant in the Medicare Program and I am not enrolled in a Health Maintenance Organization (H.M,O.), or any other Pre-Paid group practice. I understand that if it is found that I am a participant in any of the above mentioned practices, I will be considered a Self-Pay Patient and required to pay in full immediately.

C. I certify that I have received a copy of the Medicare Information Sheet. I also certify that I have received, from the Hospital, a copy of "An Important Message From Medicare" as required by the Health Care Financing Administration.

8. ADVANCED DIRECTIVES: Do you haw a Healthcare Surrogate: Yes ___ No ___ If yes, Name of Surrogate

Do you have a Durable Power of Attomey? Yes ___ No ___ If yes, obtained from Patient? Yes ___ No ___

Do you have a Living Will? Yes ___ No ___ If yes, obtained from Patient? Yes ___ No ___

I certify that I have received the Statement of Advanced Directives or Living Wills.

THE UNDERSIGNED CERTIFIES THAT HE HAS READ OR HAD THE FOREGOING INFORMATION EXPLAINED, HAS RECEIVED A COPY, AND IS THE PATIENT OR IS DULY AUTHORIZED BY THE PATIENT AS PATIENT'S GENERAL AGENT TO EXECUTE THE ABOVE AND ACCEPT ITS TERMS.

Date 12/5 , 1995

Patient's Agent or Representative

Pt medically unable to sign

Relationship to Patient

Witness: [illegible signature]

3

CONDITIONS OF ADMISSION

HCA New Port Richey Hospital<

37126000

MCPHERSON LISA