Acknowledgment of Conditions for Treatment

The undersigned Patient and/or Patient’s Representative hereby acknowledges receipt of MultiCare Health System’s Handout entitled “Notice of Privacy Practices, Conditions for Treatment, Financial Disclosures, Patient’s Right Materials, Financial Assistance,” Version 87-9158-0J (Rev. 2/24), referenced here as the Handout.

CONSENT FOR CARE: I agree to care and treatment by MultiCare Health System (“MultiCare”) that may include examinations, tests, imaging studies, labs, anesthesia, and medical or surgical treatments provided by both MultiCare employed and MultiCare affiliated physicians, surgeons and other licensed independent practitioners involved in my care. Care may be delivered via secured audio video platforms or secure, asynchronous internet-enabled platforms. Additional documents and consent forms may be required for specific procedures. I understand I have the right to ask questions about my care at any time, and to be involved in my care decisions.

Notice to Maternity Patients: My authorization for my care and the care of my baby will apply to care I receive today as well as future care related to my present pregnancy, up to and including my delivery and stabilization services thereafter.

RISKS OF TREATMENT: NO GUARANTEE OF RESULTS OR CURE: No promise or guarantee of results or cure has been made to me. I know there are risks related to surgical, medical, or diagnostic procedure(s). These risks include, but are not limited to the potential for infection, blood clots in veins and lungs, bleeding, allergic reactions, and death.

PHOTOGRAPHS FOR TREATMENT, DIAGNOSIS AND/OR IDENTIFICATION:For diagnosis and treatment purposes, I allow images such as photographs to be taken and used. This includes video and electronic monitoring or recording methods.These images may be used to add to written information about my illness or injury. Some images are used once and immediately discarded when no longer needed.Others may be kept as part of my medical record, at the option of my treatment providers. Photographs of me may also be taken for identification purposes.

IMAGES OR RECORDINGS OF HEALTH CARE PROVIDERS: I understand I must obtain the permission of all health care provider(s) and any other individuals present before I can take photographs or video of any members of my care team. I also understand I cannot record conversations by any means without first obtaining the permission of all persons being recorded. At no time may I take photos or recordings of other patients or their information.

NON-EMPLOYED PHYSICIANS & PROVIDERS: I understand there are physicians or other licensed providers who practice at MultiCare who are not employed by MultiCare. These individuals are independent providers and are not employees or agents of MultiCare. These include, but are not limited to: anesthesiologists, radiologists, emergency medicine, pathologists, hospitalists/internists, neonatologists, and PICU physicians. It also includes MultiCare Allenmore, Auburn Medical Center, Capital Medical Center, Covington, Deaconess, Good Samaritan, Navos, Tacoma General,Valley, and Yakima Memorial Hospital emergency departments physicians and providers, as well as some telehealth providers. I understand these providers use their own independent judgment in their medical care and treatment. MultiCare does not control the medical care and treatment given by these providers. I understand that MultiCare has provided me with a list of all independent providers or groups who provide care to me, together with their contact information within this handout(Understanding Your Bill section). I understand that I may receive separate bills for services provided by those parties.

FINANCIAL AGREEMENT: I agree to pay MultiCare for care at its regular rates and terms applicable to my care and any applicable health insurance coverage I have.I permit MultiCare to appeal any denial received from my insurance company. If a third party payor will not pay, I agree to pay for the services given, subject to any applicable contractual or governmental regulations. If a third party caused my injuries, I understand that MultiCare may file a medical services lien as permitted under RCW 60.44.010.(This lien attaches only to a portion of the proceeds of any settlement between me and the party that caused me harm.) If my bill is sent to a lawyer or collection agency, I will pay all reasonable attorneys’ fees and costs, together with interest and any amounts otherwise found to be owing. Information about the estimated charges for health services is available upon request. I understand I have the right to request this information.

AGENTS & CONTRACTORS: Whenever “MultiCare” is referenced herein, that term is intended to include its employees, officers, agents, attorneys, first and third party liability and claims agents, third-party claims administrators and collection agencies, as well as their agents or employees, to receive any information that MultiCare would otherwise be entitled to receive.

MEDICARE: MultiCare’s insurance and patient billing processes are consistent with the requirements established by CMS. If I am a Medicare participant, I understand that I need to pay for services that are not covered by the Medicare Program. This may include, but is not limited to, cosmetic surgery, dental care, take-home and “over the counter” medications, private duty nurses, services not medically needed, personal items, services covered by car or liability insurance, or where a third party is otherwise responsible for any accident or injury leading to my need for care, as well as any services not otherwise covered by Medicare. If I remain in the hospital at any time after it has been determined that Medicare-covered services are no longer medically necessary, I understand that I will be personally responsible for paying for such services after I am decertified as a Medicare-covered patient.

CO-INSURANCE: There may be a co-insurance for care given related to myMedicare or other insurance benefits. I know I will need to pay a higher co-insurance for services provided by a hospital-based clinic or department. If these services were given in a non-hospital based setting, my co-insurance would be lower.

ASSIGNMENT OF BENEFITS; PERMISSION TO ALLOW MULTICARE TO DETERMINE, APPLY AND OBTAIN BENEFITS, INFORMATION AND PAYMENT: I permit payment from insurance or other third-party payors to go to MultiCare directly. I permit MultiCare, in MultiCare’s sole judgment, to determine, apply for and obtain benefits, and get paid from, any and/or all available payor sources until my bill is paid in full. I understand and agree that, to the extent necessary to receive payment or reimbursement for services provided at MultiCare, I authorize MultiCare to access any applicable accident reports, industrial injury (workers compensation) reports and/or police, fire or other first responder reports or investigations related to my treatment or injury, as well as any records of any claims, lawsuits, insurance claims or investigations that pertain to my medical care and treatment, or the circumstances leading to same, together with any applicable consumer and/or credit reports pertaining to me. I further authorize any applicable Federal, State or Local government or administrative agency to fully and completely release any and all of my records and/or incident information they have about me, pertaining to my care or the circumstances leading to my need for care, upon request by MultiCare.

PHONE, EMAIL, TEXT MESSAGING AUTHORIZATIONS: I grant permission and consent to MultiCare to contact me using any email addresses or phone numbers associated with me, including wireless (cell) numbers, for any purpose related to my care, including the availability of services at MultiCare. I also represent that I am the owner or a customary user of the phone number(s) provided and have authority to grant the permission and consent to contact described herein. This consent and permission includes (1) to leave answering machine and voicemail messages for me, and include in any such messages information required by law (including debt collection laws) and/or regarding amounts owed by me; (2) to send me text messages or emails using any email addresses or cellular device numbers; (3) to send me paperless billing by email or text notifications; (4) to use pre-recorded/artificial voice messages and (5) use of an automatic dialing device (an “autodialer”) in connection with any of these communications. I understand that I am not required to accept messages in these formats as a condition of receiving services at MultiCare.I understand that I have the option to “opt out” of receiving such emails or text messages, which I may exercise at any time by following the opt out option contained in the message, or notifying MultiCare in writing to discontinue such communications using those pathways. I understand that opt out processes may take up to ten (10) business days to go into effect. Unless I have opted out, communications may continue after the expiration of this consent form.

EMAIL CONTAINING PROTECTED HEALTH INFORMATION; MYCHART*: I understand that exchanging email, text or other written communications with my health care provider(s) or other members of my care team can result in protected health information being disclosed to unauthorized persons, and that MultiCare cannot control who views such information when sent in unencrypted form. I understand that MultiCare offers “MyChart” to all patients, which provides a fully encrypted and protected pathway for communicating with most of its providers, although not all MultiCare providers choose to utilize MyChart. If I initiate or respond to communications using unencrypted pathways, I assume the risk that my information may be compromised, and I authorize MultiCare and its providers to communicate with me using that process, unless or untilI choose to opt out of such communications pathways by notifying MultiCare in writing, allowing up to ten business days to implement any change in my communications pathways. We have the right to remove MyChart privileges for disruptive behavior.

HEALTH CARE ADVANCE DIRECTIVE / LIVING WILL: I understand a health care directive, also called a Living Will, lets me choose if I want life-sustaining and other treatments in certain situations, and also lets me choose someone to make decisions on my behalf, if necessary. I understand that I have the right to create a Health Care Directive.

HEALTH CARE POWER OF ATTORNEY: I understand I have the right to nominate another person or persons to make health care decisions for me if I cannot make decisions myself. I understand that I can nominate this person using a Durable Power of Attorney for Healthcare (DPOAH) form. The person I nominate is known as a health care agent, attorney in fact, surrogate, or medical decision maker. Though neither form is required for treatment, I understand that providing MultiCare a copy of my health care directive and/or power of attorney will help my care team understand my wishes.

MENTAL HEALTH ADVANCE DIRECTIVE/POWER OF ATTORNEY: I understand that I also have the right to complete a Mental Health Advance Directive to help my care team understand my wishes concerning mental health care and treatment. I also can complete a Mental Health Power of Attorney where I can nominate another person or persons to make mental health care decisions for me.

POLST: I understand that a POLST (Physician Orders for Life Sustaining Treatment) is a medical order that is used to communicate medical care decisions to health care providers and emergency responders. If I have completed a POLST with my doctor,I agree that providers can use this to guide my care plan.

More information and downloadable forms can be found in the Patient Guide. If requested, I understand that the Handout is available in English, Spanish, Russian, and Vietnamese.

*MyChart submission is not yet available for Yakima area patients