Shawnee Mission Holistic Care Patients Consent to Treat ...

Form of Written Acknowledgment of Receipt of Shawnee Mission Holistic Care's Notice of Patient Privacy Practices

By signing below, I acknowledge receipt of Shawnee Mission Physicians Group's Notice of Patient Privacy Practices ("Acknowledgement").

Signature of Patient, or Legal Representative

_____________________ Date

Printed Name of Patient

________________________________________________ Date of Birth

Form of Written Acknowledgment and Understanding of Shawnee Mission Holistic Care's Financial Policy

By signing below, I acknowledge receipt of Shawnee Mission Physicians Group's Financial Policy ("Acknowledgement"). My signature below certifies that I have been provided a copy of SM Holistic Care's Financial Policy. It also certifies that I fully understand the contents of the policy and I hereby agree, without threat or coercion, to the terms of this policy.

Signature of Patient, or Legal Representative

Date

Shawnee Mission Holistic Care Patients Consent to Treat and Assignment of Benefits

While I am here I permit the employees, the doctor, and all other persons caring for me to treat me in ways they judge are beneficial to me. I understand the attending physician will explain to me the nature of my condition and his recommended treatment and any associated risk involved. I also understand that he/she will explain to me other ways this condition could be treated. I further understand that this care may include tests, examinations, medical and/or surgical treatment. No guarantees have been made to me about the outcome of this care.

I hereby authorize Shawnee Mission Holistic Care to release all information necessary to secure payment. I assign all benefits for unpaid services to which I am entitled to Shawnee Mission Holistic Care. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original.

Signature of Patient, or Legal Representative

Date

______________Packet Accepted ______________ Packet Declined

SMMC-67684, Rev. 3/2011

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