GUEST TERMS OF AGREEMENT

Transcription

1 GUEST TERMS OF AGREEMENT I agree for the initial evaluation in order to determine if I'm eligible for admission to Emedi Concierge (hereafter EC ) services. I request admission to the Agency and consent to such care and treatment as is ordered by my attending physician(s) through the Agency. I understand that my care is directed and monitored by my attending physician(s) and that the Agency is not liable for any act or omission when following the instruction of said physician(s), who are neither the employee nor the agent of the Agency. I consent to the release of information by any hospital, skilled nursing facility or home health agency in which I have been a patient, and authorize these health care professionals to disclose all or any part of my medical record to the Agency. I authorize the Agency to give information about my health status to other health agencies and professionals who are involved in my care, or to State, Federal and other accrediting agencies to review records, including the use of my medical chart for the purpose of Quality Improvement reviewed by the Agency. I consent that I shall not make any claims against EC,and waive all claims I may have to assert against EC. I agree in consideration of the services I am to receive, I individually obligate myself to pay the account of the Agency in accordance with the regular rates and terms of Home Health Agency. Should the account be referred to an attorney for collection, I shall pay reasonable attorney's fees and collection expenses. All delinquent accounts bear interest at the legal rate. ROOM TYPE AND RATES: DELUXE KING 1,500/NIGHT EXECUTIVE KING 1,800/NIGHT $50 credit for Food & Beverage 15% concierge fee will be applied to all additional services provided to you during your stay THE SERVICES FOR PAYMENT OPTIONS HAVE BEEN EXPLAINED TO ME. I UNDERSTAND THE SERVICES I REQUIRE AND THE PAYMENT OPTION I HAVE CHOSEN. I HEARBY ACCEPT AND AGREE TO THE PROPOSED SERVICES AND PAYMENT OPTION. The proposed services approved by my doctor will be: Skilled Nursing from the time of check-in until 10AM on the day of discharge. Page 1 of 1 (310)

2 LIABILITY WAIVER AND RELEASE I understand that EC is not a substitute for medical care of hospitalization and, as such, I am electing to use the services of EC as a matter of convenience and not for medical care, and I have provided accurate information in order for EC to assist in my recovery. I acknowledge that I am of legal age and of sound mental capacity, that I make this election free from any duress or undue influence. I understand that my medical care at all times remains the responsibility of the surgeon who performed my surgery. Only my surgeon is authorized to write prescriptions for me and to determine if outpatient recovery care is appropriate for my particular needs. I understand that my surgeon is the only party with the authority to order and perform postoperative care, including ordering my hospitalization or discharging me to a non-medical facility, such as EC or my home. While recovering at EC, I understand that I shall comply with all of EC's policies, procedures and directive from EC staff in order to ensure that I have the best possible experience. I understand that I can only bring over-the-counter & prescription medication, which my surgeon has verified and prescribed and which I may safely restart on arrival to the facility. I understand that it is my responsibility to bring the necessary prescribed medication and to place prescription and over-the-counter medications in ONE MEDICATION BAG that will be given to EC staff on arrival. I understand it is my responsibility to safely take the prescribed and any over-the-counter medication in accordance with my surgeon's recommendations, failure of which could result in unexpected complications with recovery and shall not be the fault of EC or its representatives. In any emergency 911 services is not covered by EC. I understand that I may be unsteady on my feet and i agree to request assistance out of bed for the first 24hrs following surgery.in addition,while on pain medication,i agree to remain in my recovery suite at EC unless accompanied by friend, family member or nurse. I shall comply with all directives from EC staff during this process. Further, I understand that EC has a strict NO SMOKING policy and I will be fined $300 if found smoking in my room. I understand that smoking causes significant detriment to my body's ability to heal and greatly increases my risk or post-op complications. I hereby agree NOT to smoke while at EC. Print Name: Date: Signature: Page 1 of 2 (310)

3 As part of EC services,i understand I will be staying at the hotel and I agree that Hotel is not in any way affiliated or associated with EC, and does not sponsor, any of EC services and, further, that Hotel is merely providing me a hotel room, as it would to any hotel guest, and does not provide any other services (including, but not limited to, medical or nursing), furthermore. Hotel does ensure the privacy of EC clients. I elect to utilize the services of EC, including authorizing EC to furnish any necessary transportation activities I agree to also indemnify and hold harmless EC and all of its owners, agents, officers, directors, employees and affiliates from and against any loss, accident, liability, damage, cost, expense (including reasonable attorneys' fees and disbursements and costs of investigation), judgment, charge, fine interest penalty or assessment resulting from, arising out of or relating to, any act omission or state of facts and any demand, action, suit, proceeding, claim, assessment, judgment or settlement or compromise, whether known or unknown, of any kind whatsoever that I may sustain in connection with the services provided to me by EC of any of the foregoing. I understand that this is a legally binding release and consent that the transportation services are provided in consideration for this signed release and consent. I have carefully read this Release of Liability and Consent for Transportation and Medical Treatment policy, outlined here and fully understand its contents. In order to provide the best experience possible for our clients responsible for their stay themselves, we have a 24-hour cancellation policy. A one-night deposit will be required prior to your reservation date. If you need to cancel your stay with us for any reason, please call us 24 hours before your check-in date at (310) We will return all deposits made within the 24-hour notice. In other case 50% of deposit will be retained. Additional guest staying overnight must be booked ahead of time, $200 surcharges will apply daily. Depending on length of recovery and Doctors orders your medical supplies are charged by the day. EC isn't responsible for in room ordered movies or other services provided by hotel. EC shall not be liable for any lost or damaged items during your stay. If this agreement is acceptable to you, please sign below and will keep a copy with your reservation file. Thank you for choosing EC services. We look forward to making this an extraordinary recovery experience for you. Print Name: Date: Signature: Page 1 of 3 (310)

4 RESERVATION FORM Arrival date: Departure Date: Rate: Deposit: # of guests: PATIENT/SURGEON INFORMATION First Name: Last Name: Address: Telephone: City: State/Zip: Surgeon: Surgeon Telephone: Reserved By: Date: Please be informed it is mandatory for us to obtain credit card details in order to cover any incidentals that may incur during your stay at the Hotel. Any additional services (medication,medical supplies etc) provided to you during your stay with us will be charged to your credit card and will be discussed with you in advance. Page 1 of 4 (310)

5 PAYMENT INFORMATION MC VISA AMEX Discover OTHER Name as it appears on card Address City State Zip Credit Card Number: Expiration Date: CVV Code: CARD HOLDER OTHER: (Print Name & Relationship to Holder) I authorize EC and Hotel to use my credit card for any incidental coverage incurred during my stay at Hotel. I agree that my liability is not waived in the event that the indicated person, company or association fails to pay for the full amount of the charge. Signature: Date: Page 1 of 5 (310)