Common use of Consent to Treatment Clause in Contracts

Consent to Treatment. I consent to the administration of health care by South Bend Orthopaedics This consent to treatment includes the administration of health care by the physicians employed by or associated with South Bend Orthopaedics and such assistants, residents, interns, students, or other medical personnel as may be selected and supervised by said South Bend Orthopaedics physicians. I understand that I may set condition or limitations on my treatment and care and that if I wish to provide such conditions, I will be given an opportunity to write those in a separate document. I understand that during the course of treatment, my blood or bodily fluids may come in contact with a care giver. Upon such an exposure incident testing may be necessary to determine my Hepatitis and HIV status and I give my consent for such testing. I am giving my consent to the administration of health care by South Bend Orthopaedics voluntarily. I have been informed and acknowledge that I may withdraw my Consent to Treatment at any time upon written notice to South Bend Orthopaedics. I hereby knowingly and voluntarily enter into this Consent to Treatment. By my signature below, I am acknowledging receipt of a copy of this document and agree to the terms under all sections of this document: Agreement to Pay and Benefit Assignment, Notice of Financial Interest in Health Care Entity, Consent to Treatment, and Acknowledgment of Receipt of HIPAA Privacy Policies. Signature of Patient/Guardian/Personal Representative Date Employee Witness

Consent to Treatment. I consent to the administration of health care by South Bend Orthopaedics This consent to treatment includes the administration of health care by the physicians employed by or associated with South Bend Orthopaedics and such assistants, residents, interns, students, or other medical personnel as may be selected and supervised by said South Bend Orthopaedics physicians. I understand that I may set condition or limitations on my treatment and care and that if I wish to provide such conditions, I will be given an opportunity to write those in a separate document. I understand that during the course of treatment, my blood or bodily fluids may come in contact with a care giver. Upon such an exposure incident testing may be necessary to determine my Hepatitis and HIV status and I give my consent for such testing. I am giving my consent to the administration of health care by South Bend Orthopaedics voluntarily. I have been informed and acknowledge that I may withdraw my Consent to Treatment at any time upon written notice to South Bend Orthopaedics. I hereby knowingly and voluntarily enter into this Consent to Treatment. By my signature below, I am acknowledging receipt of a copy of this document and agree to the terms under all sections of this document: Agreement to Pay and Benefit Assignment, Notice of Financial Interest in Health Care Entity, Consent to Treatment, and Acknowledgment of Receipt of HIPAA Privacy Policies. Signature of Patient/Guardian/Personal Representative Date Employee WitnessWitness Medicare Statement I request that payment of authorized Medicare benefits be made to South Bend Orthopaedics, A Division of Ascendant Orthopedic Alliance, LLC. (South Bend Orthopaedics), on my behalf for any services furnished to me by South Bend Orthopaedics. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or benefits related services. Patient: Date Medigap Statement I request that payment of authorized Medigap benefits be made to South Bend Orthopaedics, A Division of Ascendant Orthopedic Alliance, LLC. (South Bend Orthopaedics), for any services furnished to me by South Bend Orthopaedics. I authorize any holder of medical information about me to release to my Medigap insurer - any information needed to determine these benefits or the benefits payable for related services. Patient: Date