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AUTHORIZATION FOR MEDICAL AND/OR SURGICAL TREATMENT 1. I, the undersigned, a patient of Wise Regional Health System, hereby authorize Dr. ___________________________________(and whoever he/she may designate as his/her assistant(s) to administer such treatment as necessary. I also certify that no guarantee or assurance has been made as to the results that may be obtained. 2. Personal Valuables: It is understood and agreed that the hospital shall not be liable for the loss or damage to any money, jewelry, glasses, dentures, documents, furs, fur coats and fur garments, and the hospital shall not be liable for loss or damage to any other personal property. 3. Financial Agreement: The undersigned agrees, whether he/she signs as agent or as patient, that in consideration of the services to be rendered to the patient he/she hereby individually obligates him/herself to pay the account of the hospital in accordance with the regular rates and terms of the hospital. Should the account be referred to an attorney for collection the undersigned shall pay reasonable attorneys fees and collection expenses. All delinquent accounts bear interest at the legal rate. LEGAL RELATIONSHIP BETWEEN HOSPITAL AND PHYSICIAN I understand that, unless I am specifically informed in writing otherwise, all physicians and surgeons furnishing services to me including the radiologist, pathologist, anesthesiologist, and the like are independent contractors and are not the employee or agents of the hospital. I am under the care and supervision of my attending physician and it is the responsibility of the hospital and its nursing staff to carry out the instructions of my physician. It is my physician’s or surgeon’s responsibility to obtain my informed consent, when required, to medical or surgical treatment, special diagnostic or therapeutic procedures, or hospital services rendered to me under general and special instructions of my physician. I understand there will be a separate charge for professional services. I understand that the hospital does bill some professional fees; otherwise the professional fees are not included in the hospital’s bill. The undersigned certifies that he/she has read the foregoing and is the patient, or is duly authorized by the patent as patient’s general agent to execute the above and accept its terms. Date: _______________________________ Signed: __________________________________ (patient) Witness: ______________________________ or nearest relative __________________________________ Relationship to patient: __________________________________ PATIENT UNABLE TO SIGN The patient is unable to sign the release because he/she is: __ a minor __ undergoing emergency treatment __ incompetent __ transfer from nursing home/hospital Witness: ____________________________________ Date: ________________________ ______________________________________________________ Or: ___unaccompanied |