Speech/Language Therapy Services Online Registration

Request for General Treatment

I request and authorize Lake Health, its employees, my physician and other physicians or allied health professionals as are necessary to provide emergency, outpatient and/or general hospital treatment and care. Further, I authorize the hospital and my physician(s) to permit the presence of observers in my treatment as deemed necessary. I,

, understand and acknowledge that from time to time, medical students, nursing students or students of other healthcare disciplines may be undergoing clinical education in various departments at the hospital. I hereby authorize and permit such students of any such health profession to participate in my care insofar as they are properly supervised at all times by a licensed and credentialed healthcare practitioner in that field of expertise. I acknowledge that I have a right to ask questions of any physician or nurse regarding the use of students in my care at any time.

I also understand that some physicians and healthcare providers, including, but not limited to anesthesia, pathology, radiology, surgery, and emergency department providers are independent practitioners (“Independent Practitioners”) and are not employees or agents of Lake Health. They are independent contractors acting as my (patient’s) agent. Lake Health is not responsible for the acts or omissions of such Independent Practitioners.

Notice of Increased Exposure to COVID-19

I understand that during the ongoing COVID-19 pandemic, traveling to Lake Health facilities will increase my possible exposure to COVID-19. I will follow all standard safety precautions required by Lake Health and the State of Ohio when traveling to Lake Health for any treatment. I authorize Lake Health to follow standard precautions to protect myself, Lake Health staff, and other patients including taking my temperature upon arrival and asking me questions to assess my health. If I am experiencing any of the following symptoms I may be asked to reschedule my appointment: fever, shortness of breath, loss of sense of taste or smell, dry cough, runny nose, or sore throat.

Authorization to Release Information

I authorize Lake Health, Anesthesia Associates, Community Hospitalists, Inc., Drs. Hill & Thomas, Drs. Hill & Chapnick, EKG Associates, US Acute Care Solutions, and other interpreting physicians involved in my care to release any medical records or medical information necessary to file an insurance claim, to perform quality and utilization assessments, and to release any medical information which may be requested by my insurance carrier or agencies on their behalf. I authorize the release to other health organizations and/or professionals such medical information deemed necessary to ensure continuity and quality of care to my routine health care provider (Primary Care Physician) or in the event of my transfer to another institution. Further, I authorize release of medical information to a quality assurance of peer review committee or organization, compliance audits, research, marketing, Department of Health, federal and/or state agencies.

Electronic Communications

I understand that Lake Health may utilize, or make available to the healthcare professionals involved in my care, various technologies that are secure, confidential, and meet federal and state privacy and security requirements to allow providers involved in my care to communicate with each other and facilitate clinical decision-making regarding my care. Examples include, but are not limited to: secured texting, taking and sending photographs via secure technology, and other electronic communications.

Authorization to Participate in Health Information Exchanges (HIE)

Lake Health participates in one or more HIEs. Your healthcare providers can use this electronic network to securely provide access to your health records for a better picture of your health needs. We, and other healthcare providers, may allow access to your health information through the Health Information Exchange for treatment, payment or other healthcare operations. This is a voluntary agreement. You may opt-out at any time by notifying in writing the Lake Health, Health Information Management Dept. at 36000 Euclid Avenue, Willoughby, Ohio 44094.

Assignment of Benefits

In consideration of medical services to be received for this admission, I assign to Lake Health or any Hospital-Based Physician, as applicable, all, including Title XVIII of Social Security Administration, other benefits herein specified. This assignment shall be irrevocable.

Guarantee of Account

I guarantee payment of any and all hospital or Independent Practitioner charges not covered by insurance of this assignment, including court costs, if appropriate.

Your Consent for Calls and/or Text Messages to your Cellular Phone

I expressly consent to you using my cellular phone number for you, your affiliates or any third party acting on your behalf including collection agencies, calls or text messages, for collection purposes or other account related purposes. Further, I expressly consent to receiving phone calls made by an auto dialer and/or any automatic telephone dialing system from you, your affiliates or any third party acting on your behalf, including collection agencies, telephone calls for collection purposes or for other account related purposes to any cell phone number obtained from me, from any other source, or as a result of a receiving a cellular phone call from me.

Obstetrics

This consent covers this visit/admission and any subsequent visit/admission relating to this pregnancy.

Series

This consent covers this visit and any subsequent visit related to this encounter.

Patient Belongings

Patients are responsible for all money and valuables during their Lake Health admission or outpatient visit. Lake Health is not responsible and accepts no liability for lost, misplaced, stolen or retained belongings including but not limited to money, jewelry, dentures, hearing aids, eye glasses, or other prosthetic devices.

Grievance Process: Should you experience dissatisfaction with your care or services while you are a patient you may call (440) 953-6265 or ext. 6265 to report your concerns. You will be contacted and followup on your concerns will occur.