1. MEDICAL CONSENT: I, hereby, give consent to receive healthcare services provided by St. Francis Cypress Rural Health Clinic, doing business as West Feliciana Hospital. I understand that these services will be performed when I/my child is at school (Silliman Institute), during school hours where a provider from St. Francis Cypress Rural Health Clinic will examine the child. It will be my responsibility to notify Silliman Institute staff of any changes in guardianship, my child’s custody living or custody arrangements and contact numbers. I understand that that healthcare at school may consist of both preventive care services, including but not limited to: health screenings and sports physicals. An attempt will be made to notify me so that I can attend all scheduled healthcare appointments for my child, either in person or through the use of a speakerphone installed at my child’s school campus. I understand that I will receive a follow-up notice from Silliman Institute and St. Francis Cypress Rural Health Clinic if additional healthcare services are recommended for my child. I understand that a visit summary will be provided to my child’s regular primary care provider in order to ensure continuity of care. Finally, I understand that although my child will be treated at school, my child’s treatment will be provided under the supervision and care of St. Francis Cypress Rural Health Clinic and not by Silliman Institute. I further understand that although school nurses or other school personnel my assist St. Francis Cypress Rural Health Clinic in my child’s treatment (i.e. taking vitals, etc.) any such treatment is provided under the direction and care of a licensed provider with St. Francis Cypress Rural Health Clinic. Finally, I grant Silliman Institute consent to provide St. Francis Cypress Rural Health Clinic with any personally identifiably information needed in order for St. Francis Cypress Rural Health Clinic to provide treatment for my child.
2. RELEASE OF INFORMATION: The hospital may disclose all or any part of the patient’s record to any person or corporation which is or may be liable under a contract to the hospital or to the patient or to a family member or employer of the patient for all or part of the hospital’s charge, including but not limited to, hospital or medical service companies, insurance companies, and workers’ compensation carriers. West Feliciana Hospital participates in a healthcare exchange program.
3. 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 the patient or any part of liable to the patient, said benefits are hereby assigned to West Feliciana Hospital for application to the patient’s bill, and it is agreed that West Feliciana Hospital may receipt for any such payment and such payment, the undersigned and/or patient being responsible for all charges not covered by this agreement. The undersigned hereby assigns all benefits due them, to individual hospital contractors, such as pathologists, primary care and pediatric physicians.
4. STATEMENT OF PERMIT PAYMENT OF HOSPITAL AND/OR MEDICAL INSURANCE BENEFITS TO HOSPITAL (where applicable): In the event the undersigned is entitled to hospital benefits of any type whatsoever arising out of any policy of insurance insuring the patient or any party liable to the patient, said benefits are hereby assigned to St. Francis Cypress Rural Health Clinic for application to the patient’s bill, The undersigned hereby assigns all benefits due them, to individual hospital contractors.
5. STATEMENT OF PERMIT PAYMENT TO HOSPITAL AND/OR MEDICAL INSURANCE BENEFITS TO HOSPITAL (Where applicable): The undersigned guarantor hereby certifies that the information given them in applying for payment under titles XVII and XIX of the Social Security Act is correct and the hospital is authorized to release any information needed to act on this request. The guarantor also hereby requests that payment of authorized benefits be made on their behalf, and hereby assigns to St. Francis Cypress Rural Health Clinic. The guarantor understands they are responsible for any health insurance deductibles and the uninsured percentage of the remaining reasonable charges.
6. FINANCIAL AGREEMENT: The undersigned agrees, whether they sign as agent or as a patient, that in consideration of the services to be rendered to the patient, they hereby individually obligates themselves to pay the account of St. Francis Cypress Rural Health Clinic within five (5) days of the rendering of the final bill unless a verified form of third party reimbursement has been presented to and accepted by St. Francis Cypress Rural Health Clinic. If the third party does not pay within 30 days, the bill becomes the obligation of the patient or guarantor. Until such time as the account is paid in full, St. Francis Cypress Rural Health Clinic, its attorney, and/or collection agency may:
a) Utilize the resources of a consumer credit reporting bureau
b) Contact the guarantor’s employer for employment verification. Should an account be referred to a collection agency and/or attorney for collection, the undersigned shall pay all court costs and attorney fees. A service charge in the amount of 1½% (one and one-half percent – 18% per annum) on the unpaid balance or $0.50 per month. Whichever is more, will apply to this account on balances remaining unpaid after 90 days.
7. AUTHORIZATION FOR TREATMENT: The undersigned has been informed of the treatment considered necessary for the patient whose name appears below and that the treatment and procedures will be performed by physicians, members of the house staff, Registered Nurses of West Feliciana School’s. Authorization is hereby granted for such treatment and procedures. The undersigned understands that a personal physician is to be selected by or on behalf of the patient within 24 hours if further treatment is required, or immediately if complications arise. YOU HAVE THE RIGHT TO SELECT your personal physician for routine care.
8. PARENT WAIVER: To the best of our knowledge, we have given true & accurate information & hereby grant permission for the physical screening evaluation. We understand the evaluation involves a limited examination and the screenings not intended to nor will it prevent injury or sudden death. We further understand that if the examination is provided without expectation of payment, there shall be no cause of action pursuant to Louisiana R.S. 9:2798 against the team volunteer healthcare provider and/or employer under Louisiana law. This waiver, executed on the date below by the undersigned medical doctor, osteopathic doctor, nurse practitioner or physician’s assistant and parent of the student athlete named above, is done so in compliance with Louisiana law with the full understanding that there shall be no cause of action for any loss or damage caused by any act of omission related to the healthcare services if rendered voluntarily and without expectation of payment herein unless such loss or damage was caused by gross negligence.