Milestone Consent for Medical Treatment

CONSENT FOR MEDICAL TREATMENT
CONSENT FOR DIAGNOSIS AND TREATMENT: This is to certify that I, the undersigned, hereby authorize and consent to the giving of all treatments, examinations, medications, and any technical procedures which in the judgment of my physician and the medical and/or surgical staff of Franciscan Health-Olympia Fields may be considered necessary or advisable for the diagnosis or treatment of my case. I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me regarding the results of any diagnosis, treatment, surgery, test or examinations conducted or performed at Franciscan Health-Olympia Fields. I further understand that Franciscan Health-Olympia Fields is a teaching facility and as such there are physicians who hold limited licenses to practice medicine and are currently in residency programs and as such may be asked to attend me from time to time during my stay within the scope and limitation of the residency program.

AUTHORIZATION FOR RELEASE OF INFORMATION: I hereby authorize Franciscan Health-Olympia Fields and any physician or other health care provider who may treat me to release any and all pertinent information contained in my medical records to other hospitals, clinics, doctors, nurses and healthcare providers who request them for the purpose of my medical diagnosis and care, or to those organizations which pay or manage my medical care. In the event of ambulance transport, medical diagnosis, medical history and treatment information will be released to the ambulance transport service for billing purposes.This release may occur during the hospitalization and/or any time after discharge and will not expire until all claims for this hospitalization are resolved. I understand that this authorization may include information regarding medical, mental health, developmental disabilities, drug or alcohol abuse, or HIV and related diseases. This consent may be revoked at any time by written notice to the Medical Record Department (with no effect on prior disclosures).

PERSONAL VALUABLES: I acknowledge that I have been advised against keeping valuables on my person or in my room and that a hospital safe is available for storage of my valuables. I acknowledge and agree that the hospital is not responsible for any personal property, including valuables, which I choose to retain in my possession, or which are not deposited in the hospital’s safe in accord with hospital policy.

PHOTOGRAPHS: I understand photos may be taken during the course of my treatment in connection of treatment I may receive. I consent to those photos and for them to be part of my Medical Records.
I CERTIFY THAT I HAVE READ AND UNDERSTAND THIS CONSENT AND THAT NO GUARANTEE OR ASSURANCE HAS BEEN MADE AS TO THE RESULTS OR OTHER ASPECT OF ANY TREATMENT, PROCEDURE, OR TEST AUTHORIZED HEREUNDER.

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Patient's Representative's Signature
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I the undersigned acknowledge that I understand and have been advised that attending physicians and other doctors who provide treatment to me at Franciscan Health-Olympia Fields are not employees or agents of the hospital except as described in the STATEMENT OF UNDERSTANDING: PHYSICIANS ARE NOT EMPLOYEES OF THE HOSPITAL, but rather independent physicians with their own private practices. I have had an opportunity to ask and have received answers to any and all questions I have about the relationship of the physicians and the hospital. I acknowledge that the employment or agency status of physicians who treat me are not in any way a reason for nor otherwise relevant to my selection of Franciscan Health-Olympia Fields for care.
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CONSENT FOR MEDICAL TREATMENT