This agreement applies to all services provided or visits started as of today’s date. This agreement applies to The Medical College of Wisconsin, Inc. (“MCW”) and Froedtert Health affiliates: Froedtert Memorial Lutheran Hospital, Inc.; Community Memorial Hospital of Menomonee Falls, Inc.; St. Joseph’s Community Hospital of West Bend, Inc.; Froedtert & the Medical College of Wisconsin Community Physicians, Inc.; West Bend Surgery Center, LLC; Drexel Surgery Center, LLC; and Froedtert Surgery Center, LLC. The term “Affiliate” in this Agreement includes MCW and the Froedtert Health affiliate organizations listed above.
By clicking “AGREE” button I agree to the following on behalf of myself or on behalf of a minor child of whom I am a parent or legal guardian (the “Patient”):
- Notice of Privacy Practices: I have received the Joint Notice of Privacy Practices which provides information about how the Affiliate may use and disclose Protected Health Information (PHI) about the Patient. I acknowledge receipt of the privacy practices. As provided in the notice, the terms of the notice may change. If the Affiliate changes the notice, the Patient may obtain a revised copy by visiting our website at froedtert.com.
- Telemedicine Services and Risk: Froedtert Health offers primary and urgent care services to patients via telemedicine. I understand that there are potential risks to the use of telemedicine technology, including interruptions, unauthorized access and technical difficulties. I understand that my health care provider will determine whether or not the condition being diagnosed and/or treated is appropriate for a telemedicine encounter and that my health care provider or I can discontinue the telemedicine consult/visit if it is felt that the videoconferencing connections are not adequate for the situation. DO NOT USE THE SERVICES FOR EMERGENCY MEDICAL NEEDS. IF YOU EXPERIENCE A MEDICAL EMERGENCY, CALL 9-1-1 IMMEDIATELY.
- Medical Consent: I consent to the medical examination, diagnosis, and treatment via telemedicine and that this consent is effective for this episode of care as deemed necessary and proper by the authorized medical providers of the Affiliate. I understand that the Patient is under the direct care of providers during a telemedicine encounter and I expect the providers of the Affiliate to carry out their instructions. I understand that some of the providers are independent contractors and not employees of the Affiliate.
- Consent to Record, Photograph or Film: I consent to the recording or monitoring of the Patient for purposes of treatment (will be in the medical record) or for the organization’s internal operations (not in the medical record) such as quality of care and teaching.
- Student Participation: I understand that the Affiliate has educational programs and affiliations with academic institutions and I agree to student and resident participation in the Patient’s care under appropriate supervision.
Financial Agreement and Assignment: I agree, whether as agent or as the Patient, that I am financially responsible for all charges incurred. Assignment of commercial insurance benefits to the Affiliate does not reduce the responsibility for payment. Should the account be referred to any attorney for collection, I also will be responsible for reasonable attorney’s fees and any additional fees associated with the collection process. Further, I authorize payment to be made directly to the Affiliate for the benefits otherwise payable to me by any third party including major medical benefits. I understand that a service fee may be charged for the processing of any uncollectible check presented as payment for goods/services provided by an Affiliate. I agree to pay the Affiliate the patient responsibility, including co-insurance and deductibles, not covered by the patient’s insurance, subject to applicable Medicare and Medicaid advance notice requirements.
- ADVANCE NOTICE OF NON-COVERAGE
Medicare and other commercial insurance plans do not pay for everything that you or your health care provider have good reason to think you need. At this time, we expect that Medicare may not pay for this service because this type of service may not be covered by Medicare and may not be a Medicare benefit. We also expect that commercial insurance will not pay for this service.
- WHAT YOU NEED TO DO NOW
Read this patient acknowledgement and notice so you can make an informed decision about your care and ask us any questions that you may have after you finish reading. This notice gives our opinion and is not an official Medicare decision or commercial insurance coverage decision. If you have any other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-623-4227/TTY**: 1-877-486-2048). If you have any other question on commercial insurance billing, call your commercial insurance company. By providing your payment information, you are choosing to receive this health care service and acknowledge and agree that neither Medicare, Medicaid or any commercial insurance will be billed for this service and that you assume all financial responsibility of paying for this service.
- ADVANCE NOTICE OF NON-COVERAGE
- Medical Claims: I request that payment of authorized Medicare benefits, if applicable, and any Medigap Supplemental Insurance benefits identified by me and provided to or on file with the Affiliate on this date, be made either to me or on my behalf to the Affiliate for any services furnished me by that provider. I authorize any holder of medical information about me to release to Medicare, its agents, and Medigap Supplemental Insurance identified by me, any information needed to determine these benefits or the benefits payable for related services. The authorization contained in this paragraph remains in effect until the date specified for the expiration of this Agreement unless I revoke it sooner or unless I become an inpatient, at which time I will sign a new authorization.
- Intent to Donate Unclaimed Patient Refunds: Occasionally a patient is owed a refund. It is the Affiliate’s policy to refund all amounts due to patients. However, if you are owed a refund and the Affiliate is unable to locate you (or your estate) at your last-known address, the Affiliate may ultimately be required to turn over the refund to the Treasurer of the State of Wisconsin pursuant to the laws governing unclaimed property. If the monies remain unclaimed, the State Treasurer will deposit them in the State school fund. Alternatively, a patient may designate that refunds that are not claimed are donated as a gift to the Affiliate. I agree that if I am owed a refund and the Affiliate is unable to locate me at my last-known address within one year of the discovery of the refund due, or if the refund amount owed me is less than $20.00, I hereby donate the refund to the Affiliate, at the Affiliate’s discretion.
- Disclosure of Confidential Information: To the extent necessary to determine liability for payment and to obtain reimbursement, I hereby authorize the Affiliate to disclose information, including portions or all of my medical record, to any person or public or private funding sources providing health care insurance or reimbursement to or on behalf of the Patient (including, but not limited to, Medicare, Medicaid, or other insurance). I understand the specific type of information to be disclosed includes diagnosis, prognosis, and treatment for physical illness, and, where applicable - mental illness, developmental disabilities, HIV test results or AIDS or any AIDS-related diagnosis, alcoholism or drug abuse for the purpose of enabling such evaluation or treatment to be performed.
- Ongoing Care Needs: At the time of admission/registration, it is important to start considering and planning for any care that might be required after the episode of care. I understand that I have the freedom to choose and the right to select my provider for additional care. I am aware that for home health care and hospice services after discharge, the hospital will generally recommend Horizon Home Care and Hospice (an affiliate of the hospital), Froedtert & the Medical College of Wisconsin Home Infusion, or another affiliate of the hospital, unless I select a different provider. I understand that I will receive a list of other available home care agencies when specific discharge plans are discussed, and that I may ask a nurse/case manager for the list at any time.
- Notice Regarding Patient Health Care Records: I acknowledge that upon submitting a valid, written authorization, I may inspect and/or receive a copy of my health care records, including radiology reports, at my own expense. The review shall take place in the Affiliate’s Health Information Management (HIM) Department during regular business hours, upon reasonable notice. I am aware that I may authorize other persons to review and receive a copy of my medical records by signing a valid authorization form. An Authorization form that complies with the legal requirements can be obtained from the Affiliate’s HIM Department.
- Contact Made Via Telephone: I authorize Froedtert Health and its Affiliates or contractors to contact me for any purpose, including appointment reminder calls or calls for payment of services, at the current or any future numbers that I provide for my landline telephone, cellular telephone or any wireless device, including the use of automated dialing equipment or prerecorded voice or text messages.