RSUOHN

PROVIDENCEHEALTH SYSTEM‘

GENERAL CONSENT TO OUTPATIENT TREATMENTCONSENT TO PHYSICIAN OFFICE, CLINIC, OR OUTPATIENT SERVICESIrequest and authorize physician office, clinic, or outpatient care asmyphysician, his assistants or designees (collectively called “thephysicians") may deem necessary or advisable. This care may include, but is not limited to, routine diagnostic radiology and laboratoryprocedures, administration ofroutine drugs, biologicalsandothertherapeutics, and routinemedical and nursingcare. Iauthorizemyphysician(s)to perform other additional or extended services in emergency situations if itmay be necessary or advisable in order to preserve my life orhealth. Iunderstand thatmy (the patient’s) care isdirected bymy (the patient’s) physicians, and that other personnel render care and servicesto me (the patient) according to the physicians’ instructions.

I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that noguarantees or promises have been made to me with respect to the results of such diagnostic procedureor treatment.

Iunderstand that samples of body fluids and/or tissues may bewithdrawn from me (the patient) during routine diagnostic procedures.Iauthorize the facility to perform other tests on these body fluids and/or tissues inorder to further medical research and knowledge and/orto dispose of these fluids and tissues. Ifthe specimen contains fetal tissue and you do not select a private funeral home, then SJPHSmay send the tissue to the funeral home providing service to SJPHSwhere it will be cremated with other tissue from SJPHS.

Iauthorize the facility to contact healthcare providers from whom I have received treatment to obtain medical information and/orrecords including but not limited to commercialDharmacies i.e..Walgreen, CV5andalcohol and other drugtreatment recordsfor verification of mymedications.

Ihave been informed and understand that HIV (human immunodeficiency virus)/AIDS, HCV (hepatitis C virus) and HbsAg (hepatitisBvirus) tests may be performed on mewithout myconsent ifa health professional, facility employee or First Responder sustains anexposure to my blood or other body fluid.

MEDICATION &MEDICAL DEVICEASSISTANCE PROGRAMInsome cases,'the hospital may be able to obtain reimbursement for some of your medicatons or medical devices from companiesthat manufacture them. In the event this occurs, the charge for the medication or medical device is removed from your bill for thathospital stay. Most of these programs require your signature on the application forms. In order to avoid you having to sign thisapplication for each medication or device, we are requesting that you allow a Pharmacy Health Solutions (“PHS") representative tosign these forms on your behalf.

Iappoint PHS to carry out in my name, the application forms required for PHS to obtain reimbursement for my medications ormedical devices from manufacturers. This signature will be in full force from the date signed.

ASSIGNMENT OF INSURANCE BENEFITSMedicareCertification: Icertify that the information provided byme in applying for payment underTitle XVII of the SocialSecurity Act is correct and request payment on my behalf of all authorized benefits.

I hereby authorize and instruct my insurance carrier to make payment directly to the facility benefits otherwise payable to me.I agree to personally pay for any facility or physician charges that are not covered by or collected from any applicableinsurance program, including any deductibles and coinsurance amounts.

PERSONAL VALUABLESIunderstand that I(the patient) am responsible for any and all personal valuables that Ibringwith me to the facility, clinic or physician'soffice. Ihereby release the facility, clinic or physician's office from any liability for the loss or damage of any and all personalpossessions which Ichoose to keep with me during my care and treatment.

TEACHING INSTITUTIONIhave been informed and understand that this facility is affiliated with a teaching institution and the procedures performed mayrequire observation, cooperation, and services of multiple health care providers. Iauthorize residents and/or students to participatein my care.

I HAVE HAD THE OPPORTUNITYTO READ THIS FORM (ORHAVE IT READ TO ME),ASK QUESTIONSAND HAVETHESE QUESTIONSANSWERED. GENERAL CONSENT TO OUTPATIENT TREATMENTSJHS-HIPAA—2002 (4/I 1/I3)0I—9050—005 Side I 0f2

ACKNOWLEDGEMENT OF PRIVACY PRACTICESThe St.John Providence Health System Notice of Privacy Practices provides information about how protected healthinformationabout me (thepatient)—includinginformationabout human immunodeficiencyvirus (HIV),AIDS-relatedcomplex(ARC);and acquired immunodeficiency syndrome (AIDS);and includingsubstance abuse treatment records protected underthe regulations in 42 Code of Federal Regulations, Part 2. ifany; and psychological and social services records, includingcommunications made by me to a social worker or psychologist (if any)—may be used and disclosed. I have been offeredan opportunity to review the Notice before signing this consent. Iunderstand that the terms of the Noticemay change andthat Imay obtain a revised copy byaccessing the St.John Providence Health Systemwebsite at www.stiohnprovidence.orgor by contacting the PrivacyOfficer listed in the notice.

Iunderstand that Ihave the right to request restrictions on how myprotected health information is used or disclosedfor treatment, payment or health care operations. Myphysicians and the facility are not required to agree to this restriction,but ifthey agree, theywill be bound by the agreement.

Bysigning this form, I acknowledge that I have been offered and/or received the St. John Providence HealthSystem Notice of Privacy Practices.

Name of Patient (print)

Signature of Patient Date Time

Signature of Spouse Date Time

Signature ofWitness Date Time

Consent ofLegal Guardian, PatientAdvocate or Nearest Relative ifPatient is Unable to Signor is a Minor

Signature of Guardian, Patient Advocateor Nearest Relative Date Time

Relationship

Address

Phone Number

Signature of Witness Date Time

GENERAL CONSENTTO OUTPATIENT TREATMENTSide 2 of 2