I understand that my health condition requires inpatient or outpatient admission. I consent to authorized testing, treatment, and/or ASC care as ordered by my doctor and his/her consultants, associates, and assistants. I authorize Trinity Medical Center (the "ASC") nurses, employees, and others as necessary to carry out the instructions of my doctor(s) with respect to the procedures and treatment they have ordered. I understand that it may be necessary for representatives of outside health care companies to assist in my care. I also understand student nurses and others in professional training programs may be among individuals who provide care to me. It is understood that the practice of medicine is not an exact science, and no guarantee can be given as to the results of treatments, examinations, emergency services, or hospital care.

I hereby give my consent to have testing for blood-borne infectious disease, including, but not limited to Hepatitis, Acquired Immune Deficiency Syndrome (AIDS), and Human Immunodeficiency Virus (HIV) if a physician orders such test(s) or if ordered by protocol. The potential side effects of this testing are those encountered during the routine procedure of obtaining blood specimens. The minor complications may include discomfort from the needle stick and slight burning, bleeding, or soreness at the site where blood was obtained. The results of these test(s) taken under these circumstances are confidential and do not become a part of my medical record.

If I am suffering from an emergency medical condition, I authorize Trinity Medical Center to provide an appropriate medical screening evaluation and treatment, to be performed by or under the supervision of a physician or his/her aide. I understand that this condition entitles me to an appropriate medical screening and treatment necessary to stabilize my condition. It has been explained to me that the diagnostic and treatment procedures, which my emergency medical condition legally entitles me, may be limited and will include a medical screening examination. It may be necessary for me to select another physician and obtain from him/her a complete diagnosis of my condition and such continued treatment as he/she may prescribe.

I recognize that physicians and many allied health professionals who furnish services to me during this admission may be independent contractors and may not be agents or employees of Trinity Medical Center. I understand and agree that these practitioners, including physician assistants, nurse practitioners, radiologists, anesthesiologists, etc., who render professional services to me may bill and collect independently for their services. I understand that their bills will be separate and apart from the ASC's billing and collections, or the ASC may bill on the physician's behalf, but subject to the authorizations granted by me in accordance with this agreement.

Trinity Medical Center Is a physician Invested ASC. As a patient, you have the right to view the entire list of investors. Please contact ASC administration or the nursing supervisor if you would like to see the list of owners.

I have been offered Advanced Directive information and have been informed that it will be given to me at any time at my request during my ASC visit.

Patient Label Here

VIII. PATIENT RIGHTS: I hereby acknowledge receipt of a Patient Rights written statement regarding my rights as a patient of Trinity Medical Center.

IX. ACKNOWLEDGEMENT OF DEMOGRAPHIC INFORMATION: I have reviewed the attached demographic sheet and it is complete to the best of my knowledge. 

XV. Non Discrimination NOTICE: In accordance with Title VI of the Civil Rights Act of 1964 and their implementing regulations, Trinity Medical Center will, directly or through contractual or other arrangements admit and treat all persons without regard to race, color, creed, religion, sex, sexual orientation, age, marital status, disabilities, or natural origin in its provision of services and benefits, including assignments or transfers within the facility and referrals to or from the facility.

XVI. SECTION 504 NOTICE OF PROGRAM ACCESSIBILITY: Trinity Medical Center and all of its programs and activities are accessible to and useable by disabled persons, including persons with impaired hearing and vision. Access features include:

• Convenient off-street parking designated specifically for disabled persons.
• Curb cuts and ramps between parking areas and buildings.
• Level access into the ASC.
• Fully accessible offices, meeting rooms, bathrooms, public waiting areas, patient treatment areas, including examining rooms and patient wards.
• A full range of assistive aids provided to persons with impaired hearing, vision, speech, or manual skills, without additional charge for such aids.

XVII. COMMUNICATION WITH LIMITED ENGLISH-PROFICIENT PERSONS: In order to ensure effective communication and to protect the confidentiality of patient information and privacy, the services of a qualified interpreter are available to you as a patient at no additional charge. The ASC provides translation services through a telephone language service (language line) to further assist in the exchange of information between staff, employees, patients and/or families, if necessary. This service is available 24 hours per day. The language line may be accessed by calling 469-253-8736. The PIN number will be provided upon request.

Patient Label Here

The ASC is a tobacco-free facility. I understand that while I am a patient at the ASC, I may not use tobacco products.

"Pursuant to section 30.06 Texas Penal Code (Trespass by holder of license to carry a concealed handgun), a person licensed under Article 4413 (29ee), Revised status (concealed handgun law), may not enter this property with a concealed handgun.) "Pursuant to section 30.07, Texas Penal Code (Trespass by license holder with an openly carried handgun) under Subchapter H, Chapter 411, (Handgun Licensing Law), may not enter this property with a handgun that is carried openly.

I understand that from time to time it is important to photograph/videotape or mechanically record a patient's procedure or treatment for the advancement of medical care and education, and that reasonable efforts will be made to keep all material confidential if such recordings of the patient's procedure or treatment are made. I understand that I may withdraw this consent at any time except to the extent that those actions have been taken in reliance thereon.

I understand that the ASC maintains a lock box for the safekeeping of money and valuables, and the ASC shall not be liable for the loss or damage to any money, jewelry, documents, or other articles of unusual value and small size, unless placed therein. The ASC shall not be liable for loss or damage to any other personal property the patient chooses to keep in their room including dentures, glasses, hearing aids, prostheses, etc.

I understand and agree that if the ASC at any time believes there may be a weapon, explosive device, illegal substance, or drug, or any alcoholic beverage in my room or with my belongings, the ASC may confiscate any of the above items that are found and dispose of them as appropriate, include delivery of any item to law enforcement authorities.

I authorize the ASC and any physician involved in my care to release medical information and supporting documentation of same as compiled in my medical records during this admission or outpatient visit to any organization which is or may be liable or responsible for payment of charges associated with my care and for all other purposes of benefit payment. If my injury is work-related, I authorize the ASC to release any information from my medical records to my employer and/or its designee. This authorization specifically includes the release of medical information concerning drug-related conditions, alcoholism, psychological conditions, psychiatric conditions, and/or infectious diseases including but not limited to blood borne.

I acknowledge that data from my patient records will be accessible to all health care providers participating in my care or treatment, including but not limited to physicians, nurses and technicians at the ASC, ASC agencies, ambulance companies, and such other health care agencies involved in my care during and after transfer or discharge from the ASC. I further acknowledge that my medical records will be utilized in the ASC's (and the ASC's affiliates) utilization review, performance improvement, peer review and other similar processes and studies. I also acknowledge that my medical records will also be made available to government agencies as required by law. Information contained in my medical records may be extracted and compiled for research purposes and the aggregated results (without individually identifying me) may be released to the public.

Patient Label Here

I acknowledge that patient medical records at the ASC may be stored electronically and made available through computer networks to ASC personnel, as well as physicians involved in my care and their offices. I also acknowledge that should I be treated at another facility in the area affiliated with the ASC, my medical records may be made electronically available to the other facility, as well as physicians involved in my care and their offices. This will assist my physician and other caregivers in reviewing past treatment as it may affect my condition and treatment at that time. Facilities, which are not affiliated with the ASC, and affiliated facilities, which do not have computerized medical records, will not be able to provide this service. I authorize the release of my social security number in accordance with federal law and regulations to the manufacturer of any medical device I may receive. I hereby authorize payment to Trinity Medical Center, my physician, anesthesiologist, anesthetist, consultant, surgeon, radiologist or other independent contractor for all physician and ASC benefits otherwise payable to me for this period of treatment, but not to exceed the physician's or ASC's total charges.

I understand that physicians furnishing services to the patient are independent contractors and are not employees or agents of the ASC and these medical providers bill for their services separately from Trinity Medical Center. For inquiries regarding these providers' bills, please contact them directly.

In the event of an overpayment on my account, any refund due will be refunded to the appropriate party, except as follows:

It is the ASC's policy to apply any credit balance that may exist as a result of this ASC stay to any other accounts for myself. In the event there are no other accounts, a prompt refund will be made.

I hereby certify and state that I have read, and that I fully understand the above Conditions of Admission and Authorization for Medical Treatment. I have received a copy thereof, and that I have signed this Conditions of Admission and Authorization for Medical Treatment knowingly, freely, and voluntarily.

Patient Label Here

As a patient it is your right to have certain information provided to you prior to your surgical procedure in writing and verbally.

In an ongoing combined effort to maintain compliance and educate patients, Trinity Medical Center offers the following information to you regarding:

Please read through this document before your procedure. Contact us directly or speak with your Physician about any questions that may arise.

DaNelle Fitzgerald, DON at be 214-281-8687 ext 522.

When you register (on the day of your procedure) you will be asked to confirm your written and verbal receipt of this information.

Everyone has the right to make personal decisions about health care. Doctors ask whether you will accept a treatment by discussing the risks and benefits and working with you to decide. But what if you can no longer make your own decisions? Anyone can wind up hurt or sick and unable to make decisions about medical treatments.

An advance directive speaks for you if you are unable to and helps make sure your religious and personal beliefs will be respected. It is a useful legal document for an adult of any age to plan for future health care needs. While no one is required to have an advance directive, it is smart to think ahead and make a plan now. If you don’t have an advance directive and later you can’t speak for yourself, then usually your next of kin will make health care decisions for you. But even if you want your next of kin to make decisions for you, an advance directive can make things easier for your loved ones by helping to prevent misunderstandings or arguments about your care.

Although Trinity Medical Center does not honor advanced directives, upon request we will gladly provide you more detailed information and optional form(s) to assist you in writing your advanced directives.

Note: Texas law now allows an option for a person’s signature to be acknowledged by a notary instead of witness signatures and for digital or electronic signatures on the Directive to Physicians, Out-of-Hospital Do Not Resuscitate Order, and the Medical Power of Attorney, if certain requirements are met. Please have your attorney review the law in Health and Safety Code Chapter 166 for the details.

Advance directives are legal documents that allow you to convey your decisions about end-of-life care ahead of time. They provide a way for you to communicate your wishes to family, friends and health care professionals, and to avoid confusion later on.

The following is a list of documents that can be obtained from the Texas Department of Aging and Disability Services http://www.dads.state.tx.us/news_info/publications/hand books/advancedirectives.html or:

The Texas Department of Aging and Disability Services 701 W. 51st St.

Austin, Texas 78751

Phone: 512-438-3011

Mailing Address:

P.O. Box 149030

Austin, Texas 78714-9030

• Declaration for Mental Health Treatment — This document allows you to make decisions in advance about mental health treatment and specifically three types of mental health treatment: psychoactive medication, convulsive therapy and emergency mental health treatment. The instructions that you include in this declaration will be followed only if a court believes that you are incapacitated to make treatment decisions. Otherwise, you will be considered able to give or withhold consent for the treatments.

• Directive to Physicians and Family or Surrogates Form — This form is designed to help you communicate your wishes about medical treatment at some time in the future when you are unable to make your wishes known because of illness or injury.

• Medical Power of Attorney Form — Except to the extent you state otherwise, this document gives the person you name as your agent the authority to make any and all health care decisions for you in accordance with your wishes, including your religious and moral beliefs, when you are no longer capable of making them yourself.

• Out-of-Hospital Do Not Resuscitate Information & Form — This form instructs emergency medical personnel and other health care professionals to forgo resuscitation attempts and to permit the patient to have a natural death with peace and dignity. This order does NOT affect the provision of other emergency care including comfort care.

• Statutory Durable Power of Attorney — This form is for designating an agent who isempowered to take certain actions regarding your property. It does not authorize anyone to makemedical and other healthcare decisions for you

Although we strive to maintain a medically professional and compliant atmosphere, issues may arise. The Patient Grievance Procedure is a means for inquiring into an issue raised by the patient or patron, looking at the issue from all perspectives and identifying whether any action can be taken to resolve identified problems and prevent recurrence. In short, when a complaint has been made, the Facility representative (Administrator) records the conversation on a Grievance Report
followed by a prompt investigation. Every effort is made for prompt resolution. All
communication and documentation will be maintained with the Grievance Report.

Any patient and/or support person, visitor, employee, physician, or vendor may lodge a grievance using the Center’s procedure as a formal means to voice complaints, resolve disputes concerning staff actions or procedures, or bring attention to possible violations of patient rights.

No person shall be punished or retaliated against for using the Patient Grievance Procedure. Patients are encouraged to use the grievance procedures as a formal and appropriate way to express their concerns or complaints to staff and resolve disputes, instead of relying on inappropriate, acting out behaviors.

We encourage your input regarding Trinity Medical Center. Any grievances, comments and complaints will be addressed by the Facility Administrator. Complete details and a copy of the Center’s Grievance Policy and Procedure as well as a Grievance Form may be obtained by contacting the Center. Please see a representative of the center and/or request to address the administrator directly either in person by telephone or in writing. If in writing, please send to:

Trinity Medical Center
1190 N. Haskell Ave
Dallas, TX 75204

You may obtain additional information and also file a complaint to the State of Texas:

Texas Department of State Health Services 1100 W. 49th Street
P. O. Box 149347
Austin, TX 78714
1-888-963-7111
FAX: 512-834-6653
TTY: 1-800-735-2989

www.dshs.state.tx.us/hfp/complain.shtm 

You may file a complaint with Medicare through web at https://www.cms.gov/Center/Special-Topic/Ombudsman/Medicare-Beneficiary-Ombudsman-Home.html or by phone 1-800-633-4227. The role of the Medicare Beneficiary Ombudsman is to ensure that Medicare beneficiaries receive the information and help you understand you Medicare options and to apply your Medicare rights and protections.

Respecting the unique individuality of every patient is a major goal of Trinity Medical Center. To attain this goal, we have determined that the rights and responsibilities of every patient should be protected and preserved.

You have the following rights:

a) Be Free of all Forms of Abuse or Harassment.
b) Be Free from any act of discrimination or reprisal.
c) Patients shall be treated with respect, consideration, and dignity.
d) Patients shall be provided appropriate privacy.
e) Patient records shall be treated confidentially and, except when authorized by law, patients
shall be given the opportunity to approve or refuse their release.
f) When the need arises, reasonable attempts are made for health care professionals and other
staff to communicate in the language or manner primarily used by patients.
g) Patients shall be provided, to the degree known, appropriate information concerning their
diagnosis, treatment, and prognosis. When it is medically inadvisable to give such information to
a patient, the information shall be provided to a person designated by the patient or to a legally
authorized person.
h) Patients shall be given the opportunity to participate in decisions involving their health care,
except when such participation is contraindicated for medical reasons.
i) Information shall be available to patients and staff concerning:
1. patient rights, including those specified in subsections (a) - (f) of this section;
2. patient conduct and responsibilities.
3. services available at the ambulatory surgical center (ASC);
4. provisions for after-hours and emergency care;
5. fees for services.

6. payment policies;
7. patient's right to refuse to participate in experimental research.
8. methods for expressing complaints and suggestions to the ASC.
j) Marketing or advertising regarding the competence and/or capabilities of the organization shall
not be misleading to patients.
k) Patients have the right to change providers, if other providers, if qualified, are available.
You Are Responsible For:
a) Providing accurate and complete information about present and past medical conditions and
all other matters pertaining to your health.
b) Reporting unexpected changes in your condition to your health care providers. Indicating that
you clearly understand what is expected of you after your surgery/procedure.
c) Following the treatment plan recommended by your health care provider.
d) Keeping appointments and, if you cannot, notifying the proper person.
e) Knowing the consequences of your own actions if you refuse treatment or do not follow the
health care provider's instructions.
f) Being considerate and respectful of the rights of other patients and center personnel, and to
follow Center policy and regulations affecting care and conduct.
g) Ask your health professional what to expect for pain management: discuss pain relief options;
discuss openly any concerns or fears regarding pain management medications.
h) Providing a responsible adult to transport you home from the facility and remain with you for
24 hours.
i) Accept personal responsibility for any charges not covered by your insurance.

We are required by law to disclose our ownership information to you. In listing the Trinity Medical Center, we would like to take this opportunity to “Thank you!” We recognize that you have the right to choose the provider of your healthcare services. We are pleased that you have chosen Trinity Medical Center.

Trinity Medical Center is dedicated to providing the best healthcare services possible. To help accomplish this mission, Trinity Medical Center believes that all patients should know their rights and responsibilities.

Patient Rights:
1. The right to exercise these rights without regard to age, sex, economic status, educational background, race, color, religion, ancestry, national origin, sexual orientation, marital status, or the source of payment for care.
2. The right to receive information in a manner he/she understands.
3. The right to considerate, respectful care.
4. The right to know the name of the personnel who provide healthcare services to the patient.
5. The right to be well-informed about any exam performed.
6. The right to accept or refuse care, treatment, and services.
7. The right to confidentiality and privacy.
8. The right to be free of neglect, exploitation and verbal, mental, physical, and sexual abuse.
9. The right to examine and receive an explanation of the patient’s bill regardless of source of payment
10. The right to receive information on sources of help regarding advanced directives- Patients will be referred to their healthcare professional.
11. The right to file a grievance or complaint with The Health Facility Compliance Group, any governmental agency and/or any organization that awards accreditation or licensing to the Texas Department of State Health Services.
12. The right to access, request amendment to and obtain information on disclosures of health information in accordance with law and regulation.
13. The right to expect that Trinity Medical Center and its affiliates will provide service to the best of its ability.
14. The right to pain management- Patients will be referred to their healthcare provider for pain management needs.

Patient Responsibilities:
1. The patient is responsible for providing information that is relevant to the exam, including present complaints, hospitalizations, past illnesses, medications and other matters related to the patient’s health that would pertain to the exam ordered.
2. The patient needs to be considerate of other patients and personnel.
3. The patient needs to be respectful of the property of other persons and the property of Trinity Medical Center and the facility.
4. The patient and his/her family are responsible to comply with policies and procedures designed to protect the health and safety of others.
5. The patient is responsible for asking questions if instructions or requests are unclear.
6. The patient is responsible for following instructions to complete the exam.
7. The patient is responsible to inform Trinity Medical Center staff if his/her safety or dignity has been compromised during their stay.
8. The patient needs to advise his/her doctor or healthcare professional of any dissatisfaction the patient may have with his/her care or services.
9. The patient is responsible for meeting financial obligations as agreed to pay for treatment.

DISCLOSURE OF OWNERSHIP INTEREST IN TRINITY MEDICAL CENTER
Trinity Medical Center is an ambulatory surgical center in which physicians may have an ownership interest. The Center is committed to providing clinical excellence in a safe, comfortable, welcoming environment for you and your family members.

Many of the physicians who practice here have chosen to have ownership in the Center. This investment gives the physicians the ability to retain quality control and to ensure that your medical costs are reasonable, and to provide the highest quality care.
Your physician’s ownership interest in the Center does mean that your physician may benefit from choosing to perform your surgical procedure at this facility rather than in a hospital or in nother similar facility. We are therefore advising you through this document that you have the right to be treated at another facility. If you elect to have your procedure performed elsewhere, your physician will make alternative arrangements at your direction.

If you have a comment or concern regarding the services you received at Trinity Medical Center
please contact: DaNelle Fitzgerald, DON at 214-281-8687 ext 522.

Complaints and grievances may also be filed through:
The Health Facility Compliance Group (MC 1979), Texas Department of State Health Services, in writing
at: P O Box 149347, Austin, TX 78714-9347 or by phone at (888) 973-0022.

Patient safety concerns can be reported to The Joint Commission:

• At www.jointcommission.org, using the “Report a Patient Safety Event” link in the “Action Center” on the
home page of the website.
• By fax to 630-792-5636
• By mail to Office of:
Quality and Patient Safety, The Joint Commission One Boulevard Renaissance
Oakbrook Terrace, IL 60181

All Medicare beneficiaries may file a complaint or grievance with The Medicare Beneficiary Ombudsman
on-line at: www.medicare.gove/ombudsman/resources.asp