Consent for Treatment

I, the patient or his or her representative, recognize the need for medical and hospital care, authorize Reid Health and Reid Health Physician Associates (collectively Reid Health), its health care employees, allied health personnel (including Nurse Practitioners and Physician Assistants) and physicians to render such routine non-invasive medical care including x-ray examination, anesthesia, laboratory procedures, or other Reid Health services under the general and specific instruction of the physician. This form is to provide authorization for "routine" services only and not for complex diagnostic or therapeutic procedures. Except for emergency or extraordinary circumstances, it is my understanding that additional consents will be obtained by the treating physician if more invasive services are to be performed. I understand and am aware that the practice of medicine and surgery is not an exact science and acknowledge that no guarantee has been made to me as to the result of treatment or examination. I understand that it is my right to consent, or to refuse consent, to any proposed procedure or therapeutic course. I understand Reid Health supervises teaching programs and medical residency programs. Unless I inform Reid Health otherwise, students and residents shall be permitted to participate in my care. This consent for treatment is valid for up to one year for all Reid Health Physician Associates (RHPA) practices and outpatient services provided by Reid Health, excluding the Emergency Department, observation, inpatient, outpatient invasive procedures, such as outpatient surgery, cardiac caths, and interventional radiology which will be completed at each visit.

I understand the following health care professionals involved in my care are independent contractors and not agents or employees of Reid Health; this includes, but is not limited to, Locum Tenens physicians and advanced practice professionals, anesthesiologists, teleradiologists, perfusionists, contracted agency employees, non-Reid physicians/advanced practice professionals, oral surgeons and their assistants and employees, dialysis nurses and physicians/advanced practice professionals providing telemedicine in the ICU, through Reid Health Now and through teleneurology services. I understand that these providers are not subject to the control and supervision of the hospital. Reid Health is not liable for their acts. Should I have questions regarding the relationship between the health care professionals providing service to me and Reid Health, I understand that I have a right to ask further questions.

If a healthcare provider is directly exposed to my blood, I consent to be tested for infections that may put the provider at risk. I understand these test results will become part of my medical record and may have to be reported to public health officials.

COVID-19: I understand that COVID-19 is extremely contagious and is spread by person-to-person contact. I recognize that Reid Health has put in place reasonable preventative measures aimed to reduce the spread of COVID-19. I understand exposure to COVID-19 may occur whenever I enter any public place, including Reid Health and that as a result of receiving medical care I am at risk of becoming infected with COVID-19.

I understand that exposure to, and infection with, COVID-19 may result in the following: a positive COVID-19 diagnosis, extended quarantine/self-isolation, additional tests, hospitalization that may require medical therapy, Intensive Care treatment, and possible need for intubation/ventilator support, short-term or long-term intubation, other potential complications, additional care that may require treatment in a physician office, emergency room or a hospital, and the risk of death. I understand that COVID-19 may cause additional risks, in addition to the risks described herein.

I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this medical care, and I give my express permission for my provider, their staff, and Reid Health and its affiliates to proceed with the same. I understand that, even if I have been tested for COVID and received a negative test result, the tests in some cases may fail to detect the virus or I may have contracted COVID after the test. I understand that I may have COVID-19, even if I do not have any symptoms.

PATIENT DIRECTORY: I understand that I am automatically included in the patient directory which allows Reid Health to relay my location and general condition if asked for by name. If I do not want to be included in this directory, I will complete a form to be excluded. If I opt out of this directory, I understand that if family members, my clergy, neighbors or

friends who inquire about me while I am a patient, my presence here will not be shared, and that mail or flowers addressed to me will be returned.

INFORMATION RELEASE: I understand that information contained in my record may be released to physicians or other health care facilities for the purpose of treatment, payment, or health care operations.

VALUABLES: I understand that Reid Health will not be responsible for valuables, i.e., jewelry, money, clothing, eyeglasses, dentures, hearing aids, cell phones or other personal property, which is kept by the bedside. Valuables should be sent home.

PERSONAL BELONGINGS: To ensure my safety and the safety of all patients, staff, and visitors, I understand my personal items may be searched. I also understand that if the hospital decides an item could be a threat to health or safety, the hospital may (1) dispose of it, (2) put it in a safe, or (3) give it to law enforcement.

MEDICAL AND NON-MEDICAL DEVICES: I understand that devices brought from home may be used but that Reid Health will not accept liability for any injury or damage that may occur while using the device.

PRIVACY PRACTICES: I acknowledge that I have received a copy of Reid Health Notice of Privacy Practices.

PATIENT RIGHTS: I acknowledge that I have received a copy of the Hospital's Patient "Bill of Rights" brochure.

AUDIO/VIDEO MONITORING: When appropriate, Reid Health may utilize secure audio/video monitoring, as well as other technologies, as a part of patient care to help keep you safe and/or for consultation with physicians located in other locations. These technologies could include, but are not limited to, smart room technology, patient safety monitoring, and consultative telehealth services. These cameras are inactivated when personal and private care is performed. Images are not permanently stored and do not become a part of your medical record.

ARTIFICIAL INTELLIGENCE: Reid Health integrates advanced Artificial Intelligence (AI) technologies to enhance patient care and outcomes. The applications of AI include, but are not limited to, transcription of medical notes, support in clinical decision-making, personalized treatment planning, predictive health analytics and targeted outreach campaigns to address care gaps. Patient privacy is our priority, AI data will be stored securely with adherence to HIPAA laws to protect your personal information.

If I have specific questions related to the use of AI in my care, I understand that I should ask my provider for a description of such usage. Should I wish to limit or refrain from such usage, I understand it is my responsibility to discuss this with my provider.

PSYCHIATRIC PATIENTS ONLY: Your emergency services physician has determined that you are currently medically stable and do not require critical care medical services. You have been moved to a secured area to a room without critical care medical equipment, to complete a brief mental health evaluation requested by your emergency services physician. For your security and to provide a safe environment, the doors to this area are locked. In addition, this area is equipped with secure video monitoring in shared spaces along with psychiatric seclusion rooms. These videos are stored for 35 days. If you would like to leave at any time, please inform the nurse/social worker and your request will be addressed immediately using the following process: The psychiatrist will be notified of your request for discharge and within 24 hours the psychiatrist may either:

1. Place an order for your discharge as requested.
2. Place an order for your discharge against medical advice (AMA).
3. Begin involuntary commitment proceedings in accordance with State of Indiana Mental Health Laws.

FINANCIAL ARRANGEMENTS: I hereby authorize all my insurance companies to make payment directly to Reid Health that might otherwise be made payable to me, for any services furnished to me by Reid Health payable at Reid Health's charges as stated in Reid Health's chargemaster. I agree that Reid Health's usual and customary charges are those stated in its chargemaster. I understand that, upon request, Reid Health will give me an estimate of its charges for the services I anticipate receiving, and that I am free to obtain health care services from other health care providers or to compare Reid Health 's charges with those from other health care providers in deciding where to receive treatment.

I further authorize Reid Health or any of my treating providers to release medical, psychiatric, psychological, and/or other information to Reid Health's legal counsel, third-party payers, benefit administrators, guarantors and/or other persons as necessary for them to verify benefits, to determine the necessity and appropriateness of the hospital stay or services, to authorize medical services to be received, process claims for benefits, and/or to represent me in a third party payer's hearing and/or appeal process regarding payment for hospital expenses, including, but not limited to, Medicaid's hearing and appeals process. In the event of a benefit denial or payment dispute requiring member appeals or complaints, I authorize Reid Health and their representatives to act as my fiduciary or authorized representative to discuss and attempt to resolve the dispute for this and any related services on my behalf.

I understand that I am financially responsible to Reid Health for any charges my insurer may deem, in its estimate, to exceed its definition of usual and customary charges or its definition of covered and/or medically necessary services. I understand that my insurer may reduce my health benefits or reduce or deny payment to Reid Health for my services, and that I am responsible for all charges incurred as a result of my services that my insurance company does not pay, including collection costs, attorney's fees and statutory interest. I agree that any credit balance resulting from any payment, excluding insurance, may be applied to any other account I or my family owe to Reid Health, including any ancillary charges for physicians or any and all services performed during Reid Health service. I agree to promptly pay, when requested by Reid Health, the difference between Reid Health's billed charges for the services, care and treatment I received, and the amount covered by my plan benefits. Upon request, an authorized Reid Health representative will be made available to explain eligibility for financial assistance under Reid Health's policies.

I authorize Reid Health and their agents and contractors to contact me regarding my account(s) for any purpose, including for payment of services, at the current or any future number that I provide for my cellular telephone or any wireless device using automated dialing equipment or artificial or prerecorded voice or text messages.

OUT OF NETWORK PAYMENTS: I hereby acknowledge that it is my responsibility as a patient to inform Reid Health of any third-party payer that will pay for non-emergency healthcare services prior to receiving such services. Such third-party payers may include government agencies, private insurance companies, preferred provider organizations (PPOs), health maintenance organizations (HMOs), managed care organizations (MCOs), and self-insured employer plans. I understand and acknowledge that it is my responsibility to ensure Reid Health and any of its healthcare providers involved in providing such services are within my third-party payer plan's network (also known as "in-network"). If Reid Health or any of its healthcare providers are not within my third-party payer plan's network (also known as "out-of-network"), then, except as prohibited by law, I will be fully responsible for all charges related to the services I receive as a patient from Reid Health and its healthcare providers, including without limitation coinsurance, co-payments or copays, deductibles, and any additional out-of-network balances that will be billed to me. I further acknowledge I have been offered education and information related to my protection against balance billing as referenced in the Federal and State No Surprises Acts. I acknowledge that Reid Health does not participate with out-of-network reference-based billing plans.

I acknowledge that in the event Reid Health accepts partial or full payments for the services I receive as a patient, Reid Health does not accept or agree to terms that differ from the terms of this document, including without limitation terms included in insurance cards, letters, checks, or any similar communications. The receipt of such insurance cards, letters, checks (or the cashing thereof), or any other similar communications, shall not be considered satisfaction of any charges billed by Reid Health or any of the healthcare providers. If I or a third-party payer disputes any debt to Reid Health, or wishes to submit payment intended to be in full satisfaction of a debt that it is less than our billed charges, I must contact, or submit payment directly to Reid Health, ATTN: Director Revenue Cycle Management, 1100 Reid Parkway, Richmond, IN 47374.

I have read or have had an opportunity to read the Consent for Treatment, or it has been fully explained to me, and I am satisfied that I understand its content and significance. My consent is given freely, voluntarily and without reservation.

Form #500518 / 620559
Revised 4/23/2024 - Effective 7/9/2024