Sundance HealthCare Systems
Coated Valley, UNITED STATES
Challenge, Jane V.
8032 Hao Jung Road
S . fransisco
Soc. Sec. #
Responsible for Accounts
Mobile phone No .
Name & Address of Any Establishment From Which Released in Previous 60 Days
Time of Previous Admission
Dr . Archibald M. Graham
Aitemding Medical doctor
Dr . Archibald M. Graham
Admitting Diagnosis (Within 24 Hours)
Congestive heart failing, left pleural effusion, pneumonia.
Principal Medical diagnosis
Congestive center failure, still left pleural effusion, pneumonia.
Operative Procedures (Date & Title)
Discharged In ____
Autopsy Yes ____
Archibald Meters. Graham
Medical professional Signature
ENTRY SUMMARY LINEN
This is a simulated well being record made and meant for educational reasons only. All scenarios, labels, demographic information, medical occasions, and info portrayed here are fictitious. No recognition with or similarity to actual persons, living or perhaps dead, as well as to actual occasions or choices is intended or perhaps should be inferred. Any similarity to real persons or events is definitely purely coincidental. В© 2003. American Information about health Management Affiliation. All privileges reserved.
CONDITIONS OF ADMISSION
1 . CONSENT TO CLINIC CARE
I am delivering myself for admission to Sundance HealthCare Systems. I actually voluntarily consent to the object rendering of amounts which is decided to be necessary or effective in the professional judgement of my doctor. This includes routine diagnostic procedures and medical treatment by official agents and employees with the Hospital, and by its medical staff, or their designees.
I recognize that not any guarantees had been made to me as to the effect of such evaluation or treatment on my state.
2 . DOCUMENTATION TO RELEASE INFORMATION
I authorize Sundance Health care Systems to release such data from my own medical record as can be necessary for the completion of the hospital's or perhaps my physician's claims intended for reimbursement to my insurance company or firm. I UNDERSTAND THAT DISCLOSURE MIGHT INCLUDE DIAGNOSES AND OPERATIONS OR PERHAPS PROCEDURES PERFORMED AND THAT, WITH THE REQUEST OF MY INSURANCE CARRIER OR AGENCY, MY TOTAL MEDICAL RECORD MAY BE BE SUBJECT TO REVIEW. ADDITIONALLY , I UNDERSTAND THAT COPIES OF MY RECORD MAY BE ATTAINED BY MY INSURANCE COMPANY OR AGENCY.
3. ASSIGNMENT OF ADVANTAGES
In concern of the providers received in order to be received for this admission to Sundance HealthCare Devices, I give all insurance benefits due me. I actually further cause that the clinic shall be entitled to the full amount of the charges. Any kind of credit balance resulting for any reason will be applied to different existing accounts. This likewise assigns rewards to Anesthesia Consultants, COMPUTER.
I hereby agree to pay any and all clinic charges that exceed or that are not covered by my hospitalization insurance coverage. This assignment shall be irrevocable. 5. VALUABLES PLEASE NOTE
I understand that Sundance HealthCare Systems keeps a safe for the safekeeping of money and valuables. I actually, also, understand that I assume total responsibility for just about any and all of my personal valuables, money, clothing, denture, and other personal items although a patient inside the hospital until deposited together with the Hospital to get...