THANK YOU FOR CHOOSING US AS YOUR HEALTHCARE PROVIDER

I present myself for medical and diagnostic services as part of the Cardiac VIP Program (including Naples Community Hospital, Inc. and the NCH Medical Group, collectively “NCH,” “we,” or “us”). The program includes a comprehensive cardiac physical with state-of-the-art advanced imaging technology, providing a complete and detailed view of the cardiovascular system.

I voluntarily consent to the rendering of such care including diagnostic procedures and medical treatment by employees and members of the independent medical staff of NCH or their designee as may be deemed necessary or beneficial. I understand that health care providers in training, including medical students, fellows and resident physicians, may be involved in my care and treatment and I consent to their involvement in my care. In the event I need treatment or extended care not available or in the event of an emergency, it may become necessary to transfer me to a hospital. I hereby consent to this transfer when NCH determines that transfer is medically necessary.

Acknowledgement of Notice of Privacy Practices and Patient Rights

I have been given the opportunity to review the NCH Notice of Privacy Practices and Patient Rights (separate documents) prior to signing this acknowledgement and consent. NCH reserves the right to revise its Notice of Privacy Practices at any time.

By signing this document, I hereby acknowledge that I have been notified of the following:

• NCH utilizes an electronic medical record system, and this allows access to your prescription history, drug benefit coverage and enables new prescriptions to be electronically routed to the pharmacy of your choice.

• NCH may use and disclose my protected health information to carry out treatment, payment, and healthcare operations. The Notice of Privacy Practices provides a complete description of such uses and disclosures. Uses and disclosures not listed in the Notice of Privacy Practices will require my prior written authorization. I understand that I can require that medical information not be disclosed to a health plan if I pay for those services out of pocket. By signing this document, I am acknowledging that I have received the NCH Notice of Privacy Practices and understand my rights to modify how my information is used and disclosed. If NCH determines that my restrictions make it impossible for them to carry out my treatment, payment, and healthcare operations, they may refuse to accept me as a patient.

I hereby acknowledge and/or agree to the following:

1. I hereby authorize NCH to treat me and attest that the personal and financial information I provided is true and that no information has been falsified.

2. I hereby authorize NCH to contact me using my email address or cell phone number provided.

3. I have reviewed and understand the HIPAA Notice of Privacy Practices and Patient Rights as indicated with my signature and date below.

4. All imaging of cardiac structures will be read and interpreted by a Rooney Heart Institute cardiologist. For non-cardiac findings within the imaging the radiologists and/or pathologists (practitioners) who may provide services to me are not agents or employees of NCH but are independent practitioners; that NCH delegates to these practitioners  the provision of physician professional services to me, which operates to discharge NCH from any contractual obligations to provide said services to me; that NCH is not legally or vicariously responsible for the conduct or actions of these practitioners that may provide services to me.

5. I understand that the Cardiac VIP Program will not be billed to my insurance and that I am financially responsible for payment in full prior to the time of service.

6. That the undersigned does hereby release NCH, its agents, employees, officers, and directors, from liability for all acts of the aforesaid physicians, negligent or otherwise.

7. That the Hospital does not control the medical decisions, diagnosis or treatment rendered by the physicians, residents, and/or allied health professionals treating me in the Hospital; that the emergency physicians, anesthesiologists, pathologists, radiologists and hospitalists practicing in the hospital are NOT agents or employees of the Hospital but are independent practitioners; that the allied health professionals practicing in this hospital who are not employed by NCH Healthcare System, Inc. or NCH Medical Group are independent practitioners; that the Hospital delegates to physicians, residents, and/or their allied health professionals the providing of physician and/or allied health professional services to the patient, which operates to discharge the Hospital from any contractual obligations to provide said services to the patient; that the Hospital is not legally or vicariously responsible for the conduct or actions of the emergency physicians, anesthesiologists, pathologists, radiologists or hospitalists practicing in this Hospital; that the Hospital is not legally or vicariously responsible for the conduct or actions of the allied health professionals practicing in this Hospital who are not employed by NCH Healthcare System, Inc. or NCH Medical Group.

8. That the undersigned does hereby release NCH, its agents, employees, officers and directors, from liability for all acts of the aforesaid physicians and/or allied health professionals, negligent or otherwise.