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ADHISSION AGREEHENT FOR INPATIENT AND SERVICES

1. GENERAL CONSENT TO HOSPITAL SERVE: ?r'ou consent to all hospital services rendered under the general and
spatial or your physiciants}. and to the taking of plutographs and videos of you for medical treatment. scientific.
ethication. quality improvement. safety. identi?cation or research purposes. at the discretion of the hospital and your caregivers
and as permitted by law. In the event a heatthcere worker is exposed to your blood or body ?uid during your hospitalization.
we may test a sample of your blood for diseases that might be communicable. Teechirg programs for various treaitl'care
disciplines are conducted ttvcugh colleges. universities and high schools in some areas of this hospitat. Students and
residents of these programs may participate in your care.

1. LEGAL RELATIONSHIP BETWEEN HOSPITAL AND Ail physicians and surgeons fumishing services to
you while you are on any part of the hospital WW. including the emergency room and any hpatiertt or outpatient areas.
are independent contractors. They are not employees or agents of the Hospital. alhough for conveniertce the Hospital may
process bitts for their professional services. The Hospital is not legally responsibte tor the acts or ottissions of these
independent Wm- Your physicians are responsible for obtaining your informed corsent. when necessary. for surgical
or specid peacetime.

3. NURSIIG CARE: This Hospital provides only general nursing care mless your physician orders more intensive nursing or
cttier one. If your nutrition recounts the comics of a coastal duty nurse. you agree that those services must be arranged by
you or your legal representative. The Hospital is not responsible for faitu'e to provide special duty nurse services. and accepts
no liability from the provision or absence of such additional care.

4. PERSONAL The Hospital maintains a sale for the safekeeping of money and valuables. The
Hospth accepts no liability for loss of. or damage to. any item you bring to the Hospital. unless you ?rst deposit it with the
hospital for safekeeping. The liability of the Hospital for loss of. or damage to. all items you deposit with the Hospital for
safekeeping is limited to titre hundred dollars raccoon unless you are given a written receipt for a greater amount.

5. PATIENT RIGHTS: 1Ir'ou have been offered a list of Patient Rights and 

S. PRUSESS: You are encouraged to contact your nurse or the Patient Relations department with
complaints or concams about your care. If your concerns mdfor cohptaints are not resolved to your satisfaction. you may ?le
a formal grievance with Patient Relations or Administration and a hospital Grievance Committee will review your issues. For
additional interaction on fling corrpiaints about any issue please refer to potted rights and responsibilities in this decilitent.
T. in
the NdiceofPrivacyPradices. ?r?oursigrrebve betcwadumtadges your receipt ofacopyotthis NoticeAdcitionalcopiesofthe
Notice may he requested at this time. Nah: 'No stasis will automaticaly be given to any person admitted for
 substance abuse or manta health treab'nent or attempted suicide. any person admitted while in the custody of law
Setwvioral Health Services. Anyother person may add restrictions or request ?No
Information' stasis at any time. and any person may repeat that ?No lntorrnation' status be discontinued at anytime.

it. ASSISHHENT DF resonance BENEFITS FDR PHYSICIAN SERVICES: Your signature below authorises direct payment
to tftose physicists on the Hospital Medical Stall who render care to you while you are at the Hospital. This authorization cannot
be revoked. ?rou certify that you agree to this assignment of benefre. that you understand [as described in paragraph two that
your relatiorship to your physicians is independent of your relationship to the Hospital. and that you have full charity to execute
this agreement and accept its terms. ?t?ou are hereby offered a copy oithis form. NDTICE TD Medical doctors are
licenced and regulated by the Medical Board of Califon?rla. [300] 5332322 

9. HEDISAL SUPPLIES PROVIDED TO NEDIIANE PATIENTS: ti you are a patient eligible for Medicare PartAbenetils. you
acttnowtedge that title to all tangible medical related produce and devices provided to you or oortsumed while positing
services to you in the hospital ['t-tedical Stoplias?] vats in you when the ?rst of the tethering occurs: when the Hardest
Supplies are provided to you or consumed white the hospital is providing services to you; wl'ten his hospital begins to process
the Medical applies; onvhen the hospital receives payment from Medicare.

FINANCIAL AGNEEHENT: 1titiu agree. whether you sign as agent or as patient. that in consideration of the services to be
rendered to the patieM. you horeby individually obligate yomsetl to pay all hospital bills in accordance Iwith the rates as
indicated in the hospital charge description master and terms of the hospital to include service charges interest bearing
payment plans. The hospital. or other entity contracting with the hospital. may obtain credit reports from national credit
bureaus. Should the account he referred to an attomay or collection agency for collection. you shall pay all related teas and
collection expenses. All delinquent accounts shall bear interest at the legal rate.

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