patient consent - capc病人的同意-图

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1、PATIENTCONSENTFORCONSULTINGSERVICESREQUESTFORCAREANDCONSENTFORTREATMENTIrequestconsultationservicesbyPalliativeCareCenteroftheNorthShoreandconsenttosuchcareandtreatmentasisorderedbytheattendingphysician.ASSIGNMENTOFINSURANCE/MEDICARE/MEDICAIDBENEFITS

2、IauthorizepaymentdirectlytoPalliativeCareCenteroftheNorthShoreofanyinsurance/Medicare/Medicaidbenefitsotherwisepayabletomeforservices,ataratenottoexceedPalliativeCareCenteroftheNorthShore’sregularchargesforsuchservices.PRIVATEINSURANCEANDSELFPAYIagre

3、ethatinconsiderationoftheservicestoberenderedtome,IherebyindividuallyobligatemyselftopaytheamountnotcoveredbymyprivateinsurancetoPalliativeCareCenteroftheNorthShoreinaccordancewiththeregularratesandtermsoftheorganization.Afeescheduleforservicesisavai

4、lableuponrequest.AUTHORIZATIONTORELEASEINFORMATIONIauthorizethereleaseofmedicalrecordsandrelatedinformationfromPalliativeCareCenteroftheNorthShoretoauthorizedrepresentativesofmythirdpartypayororphysicianrelatedtomycare.Iauthorizereviewofrecordsforany

5、necessaryagencyauditandthereleaseofthephysicianplanofcareanddischargesummaryfrommymedicalrecorduponmytransfertoorfromanotherhealthcarefacility.Theundersignedcertifiesthathe/shehasreadtheforegoing,receivedacopythereof,andisthepatient,orisdulyauthorize

6、dbythepatient’sgeneralagenttoexecutetheaboveandacceptitsterms.Patient(Pleaseprintname)SignatureofPatientorAuthorizedPersonRelationshipDateWitnessSignatureDateIfpatientdidnotsign,pleasestatereason:COPIES:White–PCCNSPatientChartYellow–Patient/Family282

7、1CentralStreetEvanston,IL60201847.467.7423PALLIATIVECARECONSULTATIONREQUESTFORINFORMATIONFaxto:847.556.1515Date_____________Dear_____________Wehavereceivedaconsultativerequestfor(patientname)_____________________________from(referralsource)__________

8、_________________Tofacilitatetheconsultation,wouldyouindicatethereason(s)forconsultation__________________________________________________________________________________________________________________________________________________________________