• If using health insurance, please have your insurance card handy while completing the form.
• Only patients themselves, parents, or guardians may complete this form.
• You will need to submit a form for each patient you are registering.

I hereby authorize my provider to furnish my insurance company or its representative or permit my insurance company or its representative to review any information requested with respect to any illness or accident, medical history or copies of hospital and medical records. A photostatic copy of this authorization shall be considered as valid as the original. I hereby authorize payment directly to my provider for this illness or injury, of the provider’s benefits otherwise payable to me, but not to exceed my indebtedness to said provider. I agree to pay the provider for all my charges whether or not covered by this assignment. The responsible party hereby agrees that the provider’s office or the party responsible for the billing of these services may check credit with any source to obtain credit information. I authorize any holder of medical information about me to release any information needed to determine these benefits payable for related services. This release may include information which may be considered a communicable or venereal disease which may include, but are not limited to diseases such as hepatitis, syphilis, gonorrhea and the human immunodeficiency virus, also known as acquired immune deficiency syndrome (AIDS). I understand all of the above and hereby state that the information is correct to the best of my knowledge. My signature indicates that I have read the above and grant the request of authorizations. I have been notified that I may receive services from the Nurse Practitioner or Physician Assistant at this location.

TERMS AND CONDITIONS OF HEALTHCARE SERVICES

These terms and conditions of health care services must be signed by the patient or his/her authorized representative and by the party financially responsible for the patient. The below statements apply to Amberwell Health, Inc. and its subsidiaries and Affiliates, including its hospital inpatient units, swing bed units, long term care units, emergency departments, outpatient and outpatient surgery departments, and all health care providers within or associated therewith (hereafter collectively referred to as "Amberwell Health").

PLEASE READ EACH STATEMENT CAREFULLY.

1. CONSENT TO TREATMENT: I wish to be admitted to Amberwell Health ("AH") for medical services. While a patient of AH I hereby consent to medical care and treatment, including, but not limited to, diagnostic, therapeutic, and other tests and procedures as may be deemed necessary or advisable by my physician, his/her associates, partners, or designee, and AH and its employees. I consent to treatment of unforeseen conditions if deemed necessary by my physician(s). I understand that unless I object, supervised students in health training programs may observe or participate in my care. I understand that medicine and surgery are not exact sciences and that diagnosis and treatment may include, but are not limited to risks for injury, infection, allergic reaction and even death. I understand that I will be asked to provide specific consent for certain diagnostic studies, surgeries, or other treatment procedures. I acknowledge that no warranties, guarantees, or assurances have been made to me regarding the results or the outcome of any medical care or treatment provided.

2. HEALTHCARE PROVIDER EXPOSURE/BLOOD TESTING: In the event of exposure by a healthcare provider to my blood or other bodily fluids, I understand and consent to testing for communicable diseases including HIV (Human Immunodeficiency Virus - AIDS), hepatitis and other bodily-fluid borne agents that pose a health risk to such individuals. I understand that test results will be reported as permitted or required by law.

3. RELEASE OF INFORMATION: I understand my health information is confidential and will be used and disclosed by AH only as described in the Notice of Privacy Practices ("NPP") provided to me by AH.

4. PAYMENT PROVISIONS: I hereby assign, transfer and set over all health care benefits and other forms of payment of any kind which relate to the care provided to me by AH for applications to my bill. I assume full FINANCIAL RESPONSIBILITY FOR PAYMENT of all expenses associated with my care and treatment. I understand covered services will be billed to my insurance. I further understand AH is not responsible for collecting insurance nor for resolving any disputed insurance or other third party claims, and promise to pay AH all costs and charges incurred in connection with the services provided to me. I agree to pay any and all collection charges incurred if payment is not made, as well as a reasonable attorney's fee if the account is placed in the hand of an attorney for collection. I authorize any health care provider of AH to apply any overpayments to any account for services for myself, my family, or on accounts for which I am responsible. I understand that some physicians who provide services for me may not be employees of AH, but rather may be independent physicians who have been granted the privilege of using AH facilities for the care and treatment of their patients. I understand that I may receive separate bills from these physicians for their professional services provided to me.

5. CONSENT FOR CONTACT: I hereby grant permission and consent to AH, its assignees, and third party collection agents: (1) to contact me by telephone at any telephone number associated with me, including wireless numbers; (2) to leave answer machine or voicemail messages for me, and include in any such messages information required by law (including debt collection laws) and/or regarding amounts owed by me; (3) to send me text messages or emails using any email addresses I provide; (4) to use pre-recorded or artificial voice messages and/or automatic dialing device (an "autodialer") in connection with any communications made to me or related to my account.

6. MEDICARE/MEDICAID BENEFITS: I certify that the information given in applying for payment under Title XVIII or XIX of the Social Security Act, if applicable, is correct.

7. MEDICARE/TRICARE PATIENTS ONLY (For inpatient services): I have received a copy of "An Important Message from Medicare/Tricare" and understand my rights as described in that document.

8. PERSONAL BELONGINGS/VALUABLES: I understand I am, at all times, responsible for the safekeeping of my personal belongings. I understand AH cannot and will not accept responsibility for loss of any of my belongings/valuables, if they are lost or misplaced.

9. TOBACCO FREE: I understand that AH is tobacco free. I cannot smoke, vape, or use tobacco of any kind in my room or anywhere in the hospital or its grounds.