MILLWOOD HEALTH. one. (nosrtrag CONSENT FOR TREATMENT The undersigned authorizes Millw?ood Health, L.L.C., (Hospital) its staff, and attending physicians to render to the atie 11 customary care, therapy, treatment, tests and procedures considered advisable, including emergency treatment and tiansgo: t' a ion 0 another facility if necessary. Further consent is also given for any diagnostic procedures= medical treatment x-ray treatm recreational actw1ties and therapy, and other treatment ordered by Hospital and/or attending physicians including but not int; . unite to 1 services provided by pother Healthcare Professionals to the patient, has retained no medications on his/her person and agrees that all medications must be administer The undersigned affirms he/she he/she is a patient at the Hospital. a pharmacist or by a licensed nurse whil for the safety or care of the patient if the patient leaves theiprernises and he Hospital will not be responsible occur as a result of leaving against medical advice. The undersigned agrees a] for any loss or injury which may will indemnify the HOSpit The undersigned understand(s) that the use of reasonable restraint and/or con?nement in accordance with or as I applicable state law may be necessary, if severity of or behaviors warrants, in order to protect the a?iei?gtted by, . himself or others, or destroying property of the Hospital. Should such restraint and/or confinement become 1: om patients? admission, l/?W understand and agree to hold harmless the Hospital, its staff. physician. or other men?shar?glunng the from any claim resulting from any loss due to injury that may occur as a result of such?reslraint and/ r-con?nememea I authorize the noti?: myfamilv ofany seclusion or restraining episode yes . No Guardian/signi?cant other Telephone nt is under the control of an attending physician(s) and the Hospital is not iiabl said The undersigned recognizes that certain healthcare professi?3 Oi any to, radiologists, pathologists, physical therapists 80113:]; loy'ees or agents of the Hospital. The undersigned ding physicians and/or other healthcare professionals es that the patie The undersigned acknowledg he instructions 0 act or omission in following furnishing services to the patient, including, but not limited licensed social workers may be independent contractors and may not be emp further recognizes that the patient may be billed separately by their atten for their services provided. Mental Health Advance Directive Yes No Available to stay?? yes Medical Advance Directive ye; No Available to Stay?" ?Ya; ?No. an organ Yes N0 Available to sin]? wl?es ?Noo CONSENT FOR ADMISSION ce has been made to them, or the patient, as to the results of any services The undersigned acknowiedgds) that no guarantee or assuran provided to the patient, including, but not limited to, therapy, treatment, tests or procedures, while admitted to the Hospital Th . erstands that, unless otherwise disclosed, the Hospital does not employ physicians and that the patients undersigned further und admitting physician(s) and any other physician who may consult or provide services patient during this admiss employed by and are not agents of the Hospital, but are independent physicians who exercise theirjudgement in the render to patients. The underr?igned acknowledges that Millwood Hospital is a teaching facility and that professional students may have patient contact an access to the pat ?on. These students are so ervised required to meet the hospital con? ?p a licenses professronal and are ient?s medical record informed dentially standards. The undersigned authorizes the liospital'to search the personal belongings of the patient when it is reasonably believed that {h may be or 15 in 1008535510? Of an Item of ltetns may be dangerous to his/ her health or to the health of others If an ar fe Pa?ient is understood that they Will be maintained in a secure place and returned to the patientat unless otherwise 1t indicated by the attending physician. The undersigned consents to the taking of photograph(s) for the purpose of identi?cation. This photograph(s) may be retained in patient?s medical record. the loss- or damage of personal property and money not deposited in leases the Hospital from any liability for ft behind at the time of?discharged will be The undersigned re luables storage during his/her hospitalization. Any prepetty le the Hospital?s contraband/ya disposed of after 15 days. O41?l 4/04 The hospital assumes no liability for loss or damage to vehicles parked on hospital premises. Patients are encouraged NOT to leave personal vehicles on premises. CONSENT TO OUR PRESENCE The undersigned acknowledge(s) that we will give out no information unless Millwood Health, LLC has a release or authorization to do so. We will provide you'with a confidential Identi?cation Number to be used for acknowledgement. No ?owers will be accepted in accordance with hospital policy. ereby give my permission to accept mail without the Identi?cation Number. Yes No ure acknowledges you consent to allow Millwood Health, LLC to inform the patient?s Furthermore, your signat 1 sources ofpatient?s admission to and progress at Millwood Health, LLC attending physician andjor referra RESPONSIBILITY FOR DESTRUCTION OF PROPERTY The undersigned understands that patients are responsible for any damage to or destruction of Hospital property, or property may be located at the Hospital The undersigned agree to accept liability for, and reimburse the nelonging to others whic . property, which the patient may damage or destroy. Hospital or other owner 0 VVIJE The undersignedZ-acknowledgdS) that a copy of the complaint policy has been given to them, that the rights have been explained, and that they understand these rights. GUARANTEE OF The undersigned hereby agree(s) to guarantee the payment of the bill for services rendered by Millwood Health, LLC. The agree(s) whether signing as guarantor or as patient, that in consideration of the services to berendered to the patient, 0 be hereby jointly and individually obligated to pay the account of the HOSpital in accordance with the regular rates and terms of the iospital. Should the account be referred for collection by an attorney or collection agency, the undersigned agree(s) to pay all momey?s fees and other reasonable collection costs and charges that are necessary for the collection of any amount(s) not paid when ice. DISCHARGE POLICY MOWATION the undersigned understands that it is the policy of Hospital to attempt to provide a structured therapy regimen with effective quality reatment. If the treatment regimen is not completed prior to the exhausting of patients health insuranCe bene?ts; the undersigned agrees to be liable for any charges incurred which are not paid by insurance in addition to the deductible and/or co?payment liability, is NOT Hospital policy to discharge or transfer patients or and treatment regimens simply because insurance bene?ts have been :xhausted. in little WW . *thrent?ENName Patient?s Signaa?ire .- a x? Kn?, 7 {v (Ry/f l, . Wk. i (Jul-H?s 4' isn?ihreyf Insured/Guarantor v/bate Signature of Legal Guardian Next at Kin Date (For inor or lncompee Patient) 14. I . j? Agra/f ?f ?fMgA?/exf? ignature of lnsured/Co-Guarantor Date Signg?re ofi?ospital Staff Date tiff-9' ?f?l 4/04 r? trPerriRz-h