Skip to main content

Supplemental Information & Services for Patients

MULTICARE: I understand that MultiCare operates numerous hospitals, inpatient and outpatient clinics, urgent care centers and emergency departments, including free-standing emergency departments, along with many laboratory and imaging sites, and telehealth services. For a complete list of all MultiCare locations, see multicare.org. I understand that portions of my care may be rendered at more than one site or location, even when I do not move between facilities.

RELEASE OF INFORMATION: MultiCare will use and disclose my information for the purposes of treatment and care, payment for health care services, for health care operations, and as outlined in our Notice of Privacy Practices. To review this document, visit: multicare.org/patient-privacy.

HEALTH CARE WORKER EXPOSURE / BLOOD TESTING: I agree that if any health care worker (including police, fire or other first responder) is exposed to my blood or other body fluids, MultiCare may test my blood, tissue or other body fluid for communicable disease, such as hepatitis, HIV or syphilis, or other communicable diseases. I understand that any test result received because of such exposure may not appear in my medical record unless I am separately treated for any positive test results at a MultiCare facility. My test results may be shared with the exposed worker and/or their health care provider(s). I understand that a positive HIV or Hepatitis C Antibody test must be reported to the local Health Department. I understand that I may be contacted by MultiCare or others if my test is positive.

SUPPLEMENTAL INFORMATION: I acknowledge that I have been provided and/or offered the following brochures or information, and I understand that additional copies are available upon request in hard copy and/or on the MultiCare website updates-www.mccdn.io. Many of MultiCare’s forms are also translated into other languages, and I will ask if a translated version of any form is needed:

Patient Rights & Responsibilities: This brochure has important information about my rights and responsibilities as a patient. It includes MultiCare’s procedures to resolve complaints.

Notice of Privacy Practices: This describes your privacy rights and how MultiCare may use and share my personal health information, and how its participation in various Organized Health Care Arrangements and/or Clinically Integrated Networks or other Accountable Care Organizations may impact the use of my protected health information.

Financial Assistance: MultiCare offers Financial Assistance based on an individual’s ability to pay for medically necessary health care services.

Other: I may also be provided with other brochures or documents pertaining to my specific health conditions, now or at a later time. These may include communications that relate to my gender, age and generalized health condition, or that may relate to specific diagnoses, as well as general or specific information about programs or services offered by, or in conjunction with, MultiCare.

Victims of Crime: Resources may be available to victims of crimes through Crime Victims Compensation Program (CVCP) to assist with the many costs associated with violent crime. For more information on medical treatment and counseling services, contact the CVCP at 1-800-762-3716 or visit lni.wa.gov/claims/crime-victim-claims/apply-for-crime-victim-benefits/.

Interpreting and Translation Services: If English is a second language for you, and/or you otherwise need the assistance of a translator, please let us know and services will be provided.

DEAF / DEAF-BLIND / HARD-OF-HEARING SERVICES: To ensure effective communication with Patients and their Companions who are deaf, deaf-blind, hard-of-hearing, we provide appropriate auxiliary aids and services free of charge to the Patient or Companion, including sign language and oral interpreters, video remote interpreting services, written materials, telephone handset amplifiers, assistive listening devices and systems, telephones compatible with hearing aids, televisions with caption capability or closed caption decoders, and open and closed captioning of most Hospital programs. Please ask your nurse or another medical provider for assistance or contact Interpreter Services at 1-888-210-3396 for Puget Sound Region, 1-855-593-0325 for Inland Northwest and 1-833-677-5786 for Yakima.

DISCRIMINATION AND ACCESSIBILITY: MultiCare does not discriminate against any person on the basis of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity, or any other basis prohibited by state or federal law for the purpose of care and treatment or participation in its programs, services, activities or employment. MultiCare provides reasonable accommodations, including free aids and services to people with disabilities to participate or communicate effectively with us. If you are concerned about discrimination at MultiCare, please contact the MultiCare Privacy & Civil Rights Office:

To view our Compliance with the Americans With Disabilities Act, Section 504 of the Rehabilitation Act of 1973 and Section 1557 of the Patient Protection and Affordable Care Act policy, please visit: updates-www.mccdn.io/complaints-policy.

STUDENT CARE PROVIDERS: Under supervision of my health care team, I understand that medical residents, medical students, nursing students or other trainees may take part in my care and treatment.

VALUABLES: If I retain any valuables, such as wedding rings, jewelry, wrist watches, dentures, eyeglasses, hearing aids or other personal effects, instead of sending them home or placing them in safekeeping with MultiCare, MultiCare shall not be responsible for loss or damage to any personal property kept by me. I acknowledge that MultiCare recommends that I do not bring or keep valuables with me during my time at MultiCare facilities.

DISPOSAL OF REMOVED TISSUE: I allow my physician or surgeon, and/or MultiCare, to decide whether to collect or dispose of any tissue removed during any examination, treatment or procedure(s).

PATIENT SATISFACTION SURVEYS: I agree that MultiCare may contact me by phone, email or text message after my care or treatment to ask about my experience as a patient. I understand that MultiCare uses an independent agency to do this survey. I know I am not required to respond to the survey, and my participation (or not) in any survey will not impact any care that I receive.

DISRUPTIVE BEHAVIOR: I understand that MultiCare has a “zero tolerance” policy for disruptive behavior, which includes any behavior that makes it difficult for the care team to provide services. Disruptive behavior includes making discriminatory or threatening remarks to the care team or other patients and visitors. This policy protects all patients, families, visitors and MultiCare employees and providers. I agree to report any disruptive behavior to my health care team and I will take all steps that I reasonably can to avoid participating in any disruptive behavior myself, or through any friends or family members. Individuals engaged in disruptive behavior may be precluded from calling, visiting or otherwise participating in my care.

SURROGATE DECISION-MAKERS: If I am unable to sign this acknowledgment myself, I understand that my statutory surrogate decision-maker(s) will sign this acknowledgment for me, unless my consent for treatment is otherwise implied under Washington law (i.e. due to a medical emergency). If this acknowledgment is signed by a surrogate, it shall have the same force and effect as if signed by me directly, at a time and under circumstances when I would otherwise have been deemed to be competent. I understand the importance of telling my potential surrogate decision-makers of my wishes through the use of health care advance directive forms or others means, as my health conditions change over time.