I. CONSENT FOR MEDICAL PROCEDURES AND TREATMENT: Permission is hereby granted to the Crystal Clinic Orthopaedic Center, LLC (CCOC), Crystal Clinic Inc. (CCI), contracted providers, and all affiliated entities for such medical procedures, including the taking of photographs for diagnosis and treatment purposes only, as may be deemed necessary by my physician and/or his or her designee. Permission is also granted to CCOC, CCI, and affiliated entities for the taking of photographs, as reasonably necessary, for identification, health care operations and billing purposes. I consent to examinations, blood tests, laboratory and imaging procedures, medications, injections, infusions, nursing care and other services or treatments rendered by my physician, consulting physician, fellows, residents, interns, and their associates and assistants, or rendered by CCOC or CCI personnel under the instructions, orders or direction of such medical professional. I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as to the results of treatments, examinations, emergency services, or hospital care.
II. CONSENT FOR BLOOD BORNE INFECTIOUS DISEASE TESTING: 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/or 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 results of this test will become a part of my confidential medical record. I understand that refusal to consent will not result in denial of admission and/or treatment by CCOC, CCI, or any of their affiliates. Notwithstanding the foregoing, I agree that if any healthcare worker is exposed to my blood or other bodily fluid, CCOC, CCI, or any of their affiliates may perform tests on my blood or other bodily fluid to determine the presence of any communicable disease. Any test result obtained as part of this process does not become part of my medical record.
III. CONSENT FOR CORONAVIRUS (COVID-19) TESTING:I hereby give my consent for CCOC to conduct collection and testing for COVID-19 as ordered by an authorized medical provider. The results of this test will become part of my confidential medical record. I understand my test results may be disclosed to the county, state, or to any other government entity as may be required by law. I understand the risk of contracting COVID-19 may result in the potential delay of my recovery.
IV. TEACHING PROGRAMS: I understand the CCOC is a facility that promotes teaching and education opportunities and, therefore, I may be seen and examined by supervised participants as part of the educational program.
V. PERSONAL VALUABLES: CCOC, CCI and/or any of their affiliates shall not be liable for loss or damage to any personal property of the patient including dentures, glasses, hearing aids, prostheses, money, jewelry, documents, other articles of unusual value and small size, etc. I understand and agree that if CCOC or CCI at any time believes there may be a weapon, explosive devices, illegal substance or drug, or any alcoholic beverage in my room or with my belongings, the hospital may confiscate any of the above items that are found and dispose of them as appropriate, including delivery of any items to law enforcement authorities.
VI. RELEASE OF INFORMATION: I authorize CCOC, CCI, and their affiliates, and any physician involved in my care, to use and disclose health information of the patient identified herein for purposes of treatment, payment, and health care operations, including but not limited to other persons or entities assisting CCOC, CCI, and their affiliates, in their treatment, payment and health care operations activities, including to employees and agents such as external legal counsel, any billing service, collections agency, or any other agents who may work on their behalf. I authorize any applicable employee or agent assisting the aforementioned entities in securing payment for services to contact me at any telephone number associated with my account(s), including wireless telephone numbers or other numbers provided in the past, present, or future, for the purposes mentioned above, including for securing payment for services or patient satisfaction surveys. I agree that methods of contact may include using an automatic telephone dialing system, text messaging, pre-recorded or artificial voice messages, and/or other computer-assisted technology. If my injury is work-related, I authorize the aforementioned entities to release any information from my medical record 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 diseases.
VII. FACILITY DIRECTORY: I understand that CCOC maintains a patient directory which includes patient name, room number, and general condition. I acknowledge that I must request to be excluded from the patient directory. By choosing to be excluded from the patient directory, my location in the hospital will not be released to any outside party.
VIII. OWNERSHIP INTEREST: I acknowledge that I have been given the CCOC Disclosure of Physician Ownership. I understand that the hospital is owned, in part, by physicians who may be providing my care, and that a list of those physicians can be provided for review upon request.
IX. TOBACCO USE POLICY: The Crystal Clinic Orthopaedic Center is a tobacco free facility. I understand that while I am a patient at the CCOC I may not use tobacco products and/or electronic cigarettes.
X. FINANCIAL AGREEMENT:In consideration of the services to be rendered to the patient, the undersigned individually promises to pay the patient’s account at the rates stated.
I understand that I am financially responsible to the CCOC, CCI, and their affiliates for charges not covered by my insurance company(ies), except as otherwise provided by Law. In the event that CCOC, CCI, and/or their affiliates has to engage an attorney or collection agency to collect any unpaid balances that arise from the treatment consented herein, the undersigned agrees to pay the reasonable attorney’s fees and collection expenses incurred by CCOC, CCI, and/or their affiliates.
An estimate of the anticipated charges for services to be provided to the patient is available upon request from CCOC, CCI and their affiliates. Estimates may vary significantly from the final charges based on a variety of factors, including but not limited to the course of treatment, intensity of necessity of providing additional goods and services.”
Patient Accounts’ Credit Balances. Patient hereby acknowledges that, in receiving care at the Crystal Clinic Orthopaedic Center (CCOC), he/she will be treated by CCOC medical staff personnel, many of which are employed by, or contracted with, Crystal Clinic, Inc. (CCI), an Ohio professional association. CCI physicians, CCI health care providers, CCOC physicians and CCOC health care providers may bill Patient independently for certain services performed at CCOC and CCI-affiliated facilities. Patient agrees that, if as a result of payment by Patient his/her account balance with either CCOC or CCI has a credit on one or more line item(s) or date(s) of service(s) and an unpaid balance for other services, whether such services were billed by CCOC or CCI, he/she expressly authorizes CCOC and CCI to apply the credit to the open line item(s) in order to settle, in whole or in part, any amounts due to CCOC or CCI by Patient.
XI. NOTICE: The majority of physicians, including anesthesia, radiology and pathology physicians, allied health practitioners and most surgeons that render professional services at CCOC are independent practitioners and are not employees or agents of the hospital. These providers are independent contractors acting as your (the patient’s) agent. CCOC is not responsible for the acts or omissions of the providers that are not directed or controlled by CCOC.
XII. ASSIGNMENT OF BENEFITS: I hereby assign to CCOC, CCI, their affiliates and CCOC’s physicians the right to be paid directly by my health insurance carrier or other health benefit plan for the services provided to me, my minor child, or other person entitled to health care benefits for the services provided in return for the services rendered and to be rendered by CCOC, CCI and/or facility-based physicians. I hereby authorize payment of these benefits otherwise payable to be my designated insurance company(ies), except as otherwise provided by law. This assignment and transfer shall be for the purpose of granting CCOC, CCI, their affiliates and/or physicians an independent right of recovery against my insurer or health benefit plan, but shall not be construed as an obligation of CCOC, CCI, their affiliates and/or physicians to pursue any such right of recovery.
XIII. MEDICARE PATIENT CERTIFICATION: I certify that the information given by me in applying for payment under Title XVIII and Title XIX 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 / Medicaid claim. I permit a copy of the authorization to be used in place of the original and request payment of authorized benefits to be made on my behalf.
XIV. EMERGENCY TREATMENT: Crystal Clinic Orthopaedic Center does not have a doctor of medicine or doctor of osteopathy present in the hospital 24 hours per day, 7 days per week. Therefore, a doctor of medicine or doctor of osteopathy may not be present during all hours services are furnished to you. CCOC is required by Federal Regulations (42 CFR 489.20 (w)) to inform you how care is provided in case of emergency when a physician is not on site. In such instances, the Crystal Clinic Orthopaedic Center facility will provide emergency treatment within capabilities of those medical personnel present and will summon emergency medical responders from the appropriate local jurisdiction.
During your stay in the Crystal Clinic Hospital, an Advanced Cardiac Life Support trained internal medicine provider (hospitalist) will be available to assist in your care 24 hours per day and 7 days per week. This provider may be a Nurse Practitioner or a Physician’s Assistant at times when an MD or DO is not physically present on site. The Nurse Practitioner or Physician’s Assistant will always have access to a physician who is on call if the need arises.
XV. PATIENT RIGHTS AND RESPONSIBILITIES ACKNOWLEDGEMENT: I certify that I have been provided a copy of the Patient Rights and Responsibilities and have had an opportunity to ask questions.
XVI. ACKNOWLEDGMENT OF ADVANCE DIRECTIVE I LIVING WILL AND DURABLE POWER OF ATTORNEY FOR HEALTHCARE: I have been offered Advanced Directive information and have been informed that additional information will be given to me at any time at my request during my hospitalization, outpatient, or other visit.
Do you have a Living Will? Yes or No.
Durable Power of Attorney for Healthcare? Yes or No.
I acknowledge that my Living Will, according to CCOC and CCI policy, will not be implemented during any visit to a satellite facility (e.g., outpatient surgery center, hospital based physician clinic) for outpatient services, while in surgery, or during the immediate post-operative period.
XVII. NOTICE OF PRIVACY PRACTICES: I acknowledge that I have been provided a copy of the CCOC, CCI and their affiliates Notice of Privacy Practices. I understand that if I have questions or complaints, I may contact the CCOC’s HIPAA Privacy Officer.
XVIII. STATEMENT OF NONDISCRIMINATION: Crystal Clinic Orthopaedic Center and Crystal Clinic, Inc. comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability or sex.
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I hereby certify and state that I have read, and that I fully and completely understand the above Conditions of Admission and Authorization for Medical Treatment, and that I have signed this Conditions of Admission and Authorization for Medical Treatment knowingly, freely, and voluntarily.