All patients receiving care at KVH Hospital are asked to sign a Consent for Treatment form at each visit.
The undersigned hereby consents to diagnostic procedures, anesthesia, medical-surgical treatment or hospital services that may be rendered, as ordered by a healthcare professional. I understand that my care is under the control of my attending provider, his or her assistants or designees, and that the hospital is not liable for any act of omission of treatment when following the instructions of that physician.
Release of Healthcare Information
I permit the healthcare organization and the physicians or other health professionals involved in the inpatient or outpatient care to release my healthcare information for purposes of treatment, payment or healthcare operations. Healthcare information may be released to any person or entity liable for payment on the patient’s behalf in order to verify coverage or payment questions or for any purpose related to benefit payment.
Financial Agreement
I hereby assign and authorize payment directly to Kittitas Valley Healthcare for all hospital and medical insurance benefits otherwise payable to me, in an amount not to exceed the hospital’s charges for its services. I understand I am financially responsible to KVH for any charges not paid under this assignment. Should legal action become necessary to collect this bill, I understand that I will be held responsible for collection expenses.
Other Acknowledgements
I hereby consent to the release of my name, my presence in the hospital, and my condition as part of the general hospital directory, available to those who ask for me by name.
I authorize my healthcare information to be disclosed for purposes of communicating results, findings, and care decisions to my family members and others responsible for my care or designated by me.
I understand and agree that personal property such as money and jewelry should not be brought into the hospital and understand and agree that KVH shall not be liable for loss or damage any personal property.