Patient Consent Form
Below is a transcript of the Crozer-Keystone Patient Consent Form. Please see Patient Registration to review and sign a copy of this form.
Consent for Routine And Emergency Tests, Examination And Treatment
General Consent – I consent to all exams, routine testing and medical care that the doctor and/or other providers caring for me believe are needed. I understand that all patients who come to the hospital for care of a potential emergency medical condition will be given a medical screening exam. This exam and needed treatment are offered without regard to insurance or ability to pay. I accept that the services are given in the least restrictive manner and setting to meet my needs.
I understand the doctors who care for me might not be employees of the hospital. These doctors may be independent doctors who have staff privileges and have agreed to treat hospital patients. If hospitalization is necessary, I may choose a doctor or one will be chosen for me.
I understand this is a teaching hospital and students and residents may help care for me. I also understand that students and residents may observe my care.
If operations or special procedures are needed, I will be asked by my doctor to give separate informed consent.
I accept my care may require the use of a range of medical devices and equipment.
I understand medicine is not an exact science and no promises or guarantees have been made about my treatment or outcome.
Safety - I understand that I have a duty to take part in the safe delivery of my care. I agree to provide true and complete information to hospital staff and to report changes in my condition. I will ask questions so that I understand my condition and the care given to me. I agree to follow directions and I agree to accept blame for any and all harm caused by my failure to follow these directions. I will treat my care providers, other patients, and hospital property with courtesy and respect. I will not leave the treatment area without my doctor’s consent. I will follow all hospital rules, including not smoking. If I am a smoker, I may ask my doctor for help to manage my cravings.
Right to Refuse - I have the right to refuse any drugs, treatment or procedure. I understand that my refusal may cause a great risk to my health. I accept this risk.
Personal Property - I understand the hospital is not responsible for any money or personal belongings kept by me during my treatment. I should send my belongings home. If that is not possible, the hospital has a safe, where I can put my belongings. The hospital will NOT be responsible for lost money and/or lost or damaged personal belongings not placed in the safe.
Consent to take and share photos and video for treatment including telemedicine, quality review and education - I allow Crozer-Keystone Hospitals, agents and employees to record photographs, and video and audiotapes of me for the purpose of treatment, identification, documentation and/or monitoring of my medical condition. Treatment may include electronically sharing photographs, radiology films, reports and/or 2-way video consultation with providers that are not in the hospital. This is called Telemedicine. The images may or may not be recorded. If images are recorded, they may become part of my medical record and may also be used for quality review purposes. The recording will not be used for any other purpose unless I have given separate consent. Video monitoring, which is not recorded, may be used when I am in certain clinical areas.
Specimens – I agree this hospital may retain, discard, preserve and/or use for scientific or teaching purposes, any specimens or tissue taken from my body during the course of my care.
Labor and Delivery Patients - Your signature on this form is your consent for both you and your baby (or babies) born during this hospital stay.
Agreements for Financial Responsibility and Assignment of Benefits - I authorize payment to the hospital of any hospital insurance benefits payable to me, by the insurance company. This payment may not be more than the balance owed to the hospital after my insurance has paid. I understand I have to pay the hospital for all charges not covered by my insurance. If my insurer or doctor tells me that care should be given in another clinical setting, is non-emergent, or not covered by my insurance, I may still be treated but I may have to pay for care given.
I understand the hospital will bill me for care given by hospital employees and I will receive separate bills from doctors and others who provide care to me that are not employed by the hospital.
I assign and transfer to the hospital and doctors who care for me any and all benefits of any kind that are payable for hospital care, doctors’ care, or other services given to me. Benefits include but are not limited to, any and all insurance payments, Medicare and/or Medicaid payments, and/or payments payable under an Employer Self-Funded Medical Expense Reimbursement Plan as governed by the Employee Retirement Income Security Act (ERISA). This allows the hospital and doctors who cared for me to act in their own names, and in my place, to accept and collect any and all payments of any kind that would be payable to me. This allows the hospital to sue any insurer or other responsible party to recover these payments just as I could do. This does not in any way, reduce, release, compromise, or otherwise affect my financial responsibility to the hospital for any and all unpaid hospital, doctor or other charges for my care. This is binding upon my administrators, executors, heirs and successors.
Release of Information - I consent to the hospital releasing information about me and my care, including my medical record, to any health care provider, social service agency, or institution providing care to me, including those I am referred to after discharge. I also consent to the hospital’s use and disclosure of my personal health information for other hospital-approved purposes like administration, education, utilization review, quality improvement, peer review and to seek payment from health insurance or other responsible parties.
Privacy Practices - Health Insurance Portability and Accountability Act (HIPAA) – The Notice of Privacy Practices explains how your protected health information (information about you and your medical condition) may be used or disclosed.
Patient Rights - Under Federal and State law, patients have certain rights and must be informed of them.
Verification - I certify that the information I have provided about me is correct; this includes my name, date of birth, social security number, current address, current phone number, and current insurance information. I understand that if this information is false and I have given another person’s identification or insurance information, the hospital may report me to the police.