Please select the clinic you would like to attend.
Your actual appointment could vary by 15 minutes.
1) MEDICAL AND SURGICAL CONSENT I, the under signed,consent to the services which may be performed during this outpatient visit,including office visit, which may include but are not limited to laboratory procedures,radiology procedures, diagnostic procedures, stress testing, rendered to me under the general and special instructions of my provider. This consent includes testing for blood-borne infectious diseases, including but not limited to Hepatitis, Acquired Immune Deficiency Syndrome (AIDS), and Human Immunodeficiency Virus (HIV), if a provider orders such tests for diagnostic purposes. If the patient takes any medications or other substances without orders from the provider, the patient hereby releases the hospital and provider from liability for any reaction that may occur. In the event of an emergency, I authorize Mountain View Hospital (MVH) to transfer myself to another healthcare facility should my provider determine it necessary. In addition, I also consent to the release of my medical records to such facility.
2) RELEASE OF INFORMATION I authorize the clinic and any physician involved in my care to release medical information and supporting documentation of same as compiled in my medical records during the out patient visit to any organization which is or may be liable or responsible for payment of charges associated with my care. If my injury is work-related, I authorize the clinic to release any information from my medical records to my employer and/or its designee. I acknowledge that data from my patient records will be accessible to all health care providers participating in my care or treatment, including but not limited to physicians, nurses and technicians at the hospital, home health agencies, ambulance companies, and such other healthcare agencies involved in my care. I acknowledge that patient medical records at the clinic are made available through computer networks to hospital personnel, providers involved in my care and their offices.
3) PATIENT PRIVACY I have read and/or received the information entitled "HIPAA NOTICE OF PRIVACY PRACTICES" available to me at
I have received and/or had the opportunity to review MVH's"Notice of Privacy Practices" either in electronic or paper form. Any questions that I had have been answered.
4) PATIENT RIGHTS MVH has adopted an extensive Patient Rights Policy, which affords patients' rights to respect and foster the patient's dignity, autonomy, positiveself-regard, civil rights and involvement in their case. These rights are posted through out our hospital and clinics, available on our website, or available by asking the admissions desk for the Patient's Rights pamphlet.
5) WEAPONS/EXPLOSIVES/DRUGS: I understand and agree that if the hospital at anytime believes there may be a weapon, explosive device, or illegal substance or drug, or any alcoholic beverage in my room or with my belongings, the hospital may search my room and my belongings, confiscate any of the above items that are found, and dispose of them as appropriate, including delivery of any item to law enforcement authorities.
6) FINANCIAL AGREEMENT AND ASSIGNMENT OF INSURANCE BENEFITS In consideration of clinic services rendered, I hereby authorize payment directly to the above named clinic for benefits otherwise payable to me, but not to exceed the clinic's regular charges. In addition, I authorize payment of Medicare/Medicaid/Insurance benefits to any contracted provider; this includes, but is not limited to laboratory procedures, radiology procedures, and anesthesia, pathology, or hospital services rendered to me under the general and special instructions of my provider during this encounter. I understand that I am financially responsible for charges not covered by my plan. In the event that I receive a bill for services covered by my insurance plan, I agree to immediately advise the clinic of my insurance coverage for such charges. In the event that this account is not paid according to the terms of the clinic's credit policy, I agree to pay interest at the rate of 18% APR and/or costs of collection, not to exceed reasonable legal fees and court costs. If my account is assigned to a collection agency for collection and suitis filed to recover payment I agree to pay as a reasonable attorney's fee 33% of the principal and interest on my account balance, or any sums awarded by the court, whichever is greater, I further agree to pay reasonable cost of suit.
7) MEDICARE PATIENT CERTIFICATION I certify that the information given by me in applying for payment under Title XVII or 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 inter mediariesor carriers any information needed for this or a related Medicare 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.
8) MOUNTAIN VIEW HOSPITAL IS A PHYSICIAN OWNED HOSPITAL Upon request a List of Ownership will be provided to you.
I hereby certify and state that I have read, and that I fully and completely understand the Conditions of Admission and Authorization for Medical Treatment, and that I have signed the Conditions of Admission and Authorization for Medical Treatment knowingly, freely, and voluntarily. Moreover, I certify and state that I have received no promises, assurance, or guarantees from anyone as to the results that may be obtained by any medical treatment or services.