1. CONSENT FOR MEDICAL TREATMENT/ADMISSION: I hereby consent to treatment at Inhospital Physicians Corp and authorize each of its physicians, practitioners, health care professionals, employees and members of its Medical and Dental Staff to render medical care. I have verified that my name and all demographic information on my Admission Form and Hospital identification band are correct. I understand the medical care that I receive at this facility may include, and not be limited to, laboratory tests, diagnostic procedures, therapy, examinations and administration of medications, etc. I understand that the practice of medicine is not an exact science and that diagnosis and treatment may involve risks of injury or even death. I understand and acknowledge that no guarantees have been made to me about the outcome of my care. I further grant Inhospital Physicians Corp or other designated institution permission to use my blood, urine or other bodily fluids, tissue and other specimens, which may become necessary for removal during treatment for the purposes of pathological diagnosis, advancement of medical science and education, or specimen disposal in accordance with routine hospital practice and government regulations.

2. RELEASE OF INFORMATION: I hereby authorize Inhospital Physicians Corp to release part or all of my medical and billing record (as necessary to either determine eligibility for health benefits or verify, collect or purse my account) to any person, corporation, agency or entity that is either responsible for payment of the cost of care provided to me, or involved in the collection, processing, verification, or payment of my account, regardless of whether I am eligible for reimbursement by a third-party payer. The information released may include information regarding psychological, psychiatric, HIV and related diagnosis, venereal disease, or drug or alcohol related illness. My consent to the release of this information is subject to revocation at any time, expect to the extent that the party which is to make the disclosure has already relied upon my consent. I authorize Inhospital Physicians Corp to release information to outside healthcare institutions, agencies, or physicians as necessary to maintain continuity of care post discharge. I acknowledge I have been provided Inhospital Physicians Corp’s “Notice of Privacy Practice” to read, and any questions I had were answered to my satisfaction.

3. PATIENT RIGHTS: I acknowledge that I have been offered a copy of the Hospital’s Patient Handbook. I further acknowledge that I have been provided information on Advance Directives, the Hospital’s Privacy Policy, and the New Jersey Department of Health document entitled “Your Right to Make Health Care Decisions in New Jersey.”

4. IMAGES: I consent to the use of photography or videotaping relating to my medical condition. I understand that any images may be used for my treatment and/or medical education. If used for medical education, at no time will my identity or any information linked to my identity be disclosed. The Hospital will protect the confidentiality of my images in accordance with all applicable federal and state privacy laws.

5. ASSIGNMENT OF BENEFITS: I authorize payment directly to Inhospital Physicians Corp for hospital/medical insurance benefits (from Medicare, Medicaid, commercial insurance, worker’s compensation, auto insurance, etc.) that I might be entitled to for the charges of the care/treatment provided to me. I hereby assign to the Hospital and/or physician all rights, title and interests that I may have to receive payment from a health insurer or other payor for services rendered at Inhospital Physicians Corp. I authorize Inhospital Physicians Corp to appeal on my behalf any denial by my insurer or payor for coverage of such services.

6. FINANCIAL AGREEMENT: For and in consideration of care and treatment provided, I hereby guarantee payment of all charges not covered or paid by my insurance benefits including Medicare, Medicaid, work’s compensation, and no-fault insurance. I hereby agree to all pre-certification requirements as stated in my health insurance policy. I acknowledge that I am responsible for any charges for health care services that are not pre-certified or pre-authorized by my insurance.

7. NOTICE REGARDING MEDICAL PROVIDERS: I understand that the physicians or other practitioners involved in my care may not be Hospital employees or agents, but instead independent contractors granted the privilege to use the Hospital’s facilities. Independent contractors are responsible for their own actions and the Hospital is not liable for their acts or omissions. I acknowledge that in addition to my Hospital bill, I may also receive separate bills from physicians for their professional services (i.e., anesthesia emergency services, pathology, radiology, etc.). I acknowledge that I am responsible for any charges for these professional services that are not covered by my health insurance benefits.

8. PERSONAL VALUABLES: I understand that Inhospital Physicians Corp is not responsible or liable for the loss of or damage to, any valuables such as money or personal articles unless they are deposited in the facility safe. These items should be sent home with family or friends and I will accept full responsibility for any items I retain in my possession.