CONDITIONS OF REGISTRATION / GENERAL TERMS AND CONDITIONS OF SERVICE

Except in an emergency situation, each patient or his or her representative is required to sign this form, without any deletions or modifications, before receiving care from North Bend Medical Center.

1. Consent for Care and Treatment. I consent to all medical care and treatment considered necessary, routine or advisable for my care or the care of the person for whom I am signing this consent. I agree that this consent shall apply to care and treatment provided by North Bend Medical Center’s employed, independent contractor, onsite and remotely-working physicians and other health care providers. I understand that all medical care involves risks, including risks of injury and even death. I acknowledge that no guarantees have been made, or can be made, about the effectiveness, safety or outcome of the care and treatment provided under this consent.
2. Consent for Exposure Testing. In the event a healthcare worker is exposed to my blood or body fluid in a manner posing a risk for transmission of a blood-borne infection, I give my consent to be tested for infections such as HIV, Hepatitis B and Hepatitis C at no cost to me, so the necessary tests and treatments can be administered to at-risk healthcare workers as a result of exposure. In such situations, I authorize release of applicable information to the healthcare worker(s) and his/her healthcare provider(s). If an exposure event occurred while I was in surgery, testing may occur while I am under anesthesia. I understand that I will be notified if any such testing has been performed, in which case I can obtain the results of the tests from my physician and have them explained to me.
3. Phone Calls. I understand and agree that North Bend Medical Center and its agents may contact me about my condition, my health care, the payment for my health care, and other matters. I consent to the use of any contact information and telephone numbers, including cellular telephone numbers, that I have provided to North Bend Medical Center for this purpose. Also, I consent to the use of automatic dialing equipment, pre-programmed voice messages, and related technologies for making calls to me. I understand that I may be charged for some of these calls, depending upon the terms of my telephone service plan.
4. Payment for Care and Treatment. I agree to pay for the care and treatment provided to me or to the person for whom I am signing this consent. I understand that I am financially responsible for the cost of all such care and treatment that is not covered by insurance or other payers, as well as for the cost of applicable copayments, deductibles, and coinsurance amounts. I also understand that many independent physicians and health care providers issue different bills, offer different discount and payment terms, and have different insurance arrangements than North Bend Medical Center. I hereby assign and transfer to North Bend Medical Center the right to receive payment and other benefits from any insurance or other payer plans covering the care and treatment provided to me or the person for whom I am signing this consent. I agree to pay all charges, late fees, accrued interest, attorneys’ fees, and collection costs, resulting from my unexcused failure to pay in a timely manner. I understand that, depending upon my financial circumstances, I may be eligible under North Bend Medical Center’s financial assistance policy for reductions or waivers of North Bend Medical Center medical bills. I also understand that North Bend Medical Center may perform credit checks and other screenings in connection with its billing and payment activities.
5. Patient Rights. I understand that North Bend Medical Center recognizes those patient rights and responsibilities that are described in the Patient Rights and Responsibilities document. I understand that patients do not have the right to demand, and North Bend Medical Center is not required to provide, medical care or treatment that is deemed futile, unnecessary or inappropriate. I also understand that, in order to protect the privacy rights of patients and staff, North Bend Medical Center does not allow the taking of films, photographs or other video or auditory recordings within its facilities, except where permitted by specific department policies.
6. Responsibility for Valuables and Possessions. I understand and agree that North Bend Medical Center is not responsible for watching, keeping track of, repairing or replacing any personal valuables or possessions (including money, jewelry, personal electronic devices, glasses, hearing aids, dentures, etc.) brought on North Bend Medical Center’s premises by patients, their family members or visitors. I understand that individuals are encouraged not to bring such valuables or possessions onto North Bend Medical Center's premises. On behalf of myself and the person for whom I am signing this consent, I hereby release North Bend Medical Center from any and all liability for loss of, theft of, damage to, negligence relating to personal valuables or possessions that are not committed to safekeeping.
7. Cancellation and no-show agreement. No-shows occur when a patient fails to arrive on time for a scheduled appointment or has failed to give a 24-hour cancellation notice. I understand and agree that North Bend Medical Center may charge $75 per no-show visit. I understand that my provider may choose to terminate the patient provider relationship at any time resulting from no-shows or cancellations.
8. SMS Messaging. When you sign up for text messages from North Bend Medical Center you are signing up to receive text messages related to your relationship with North Bend Medical Center, including updates related to your visits, MyChart account, one-time passcode, billing notifications, and care management. Messages may be received from St.Charles&CarePartners. You can opt-out of SMS messages by texting STOP to respective short code. Your opt-out request will generate one final message confirming that you have been unsubscribed. You will no longer receive SMS messages from the short code you opted out from. If you want to join again, sign up using MyChart or text HELP to the short code (84823) for instructions. If you are experiencing issues with the messaging program you can reply with the keyword HELP for more assistance, or you can get help directly at 844-259-4153. Carriers are not liable for delayed or undelivered messages. Message and data rates may apply for any messages sent to you from us and to us from you. Message frequency may vary.

Maintenance of the Healing Environment. I understand that North Bend Medical Center works to create a safe and healing environment for its patients and, therefore, reserves the right to discontinue the treatment of any patient who is, or whose family member or guest is, disrupting the healing environment. I understand that North Bend Medical Center also reserves the right to remove from its facilities and/or turn over to law enforcement any individual who is engaging in dangerous, threatening or disruptive behavior, and any weapon, item or substance that is illegal, dangerous, or has the potential to cause harm.