Preview
LAW OFFICE OF V. MICHAEL SIMKO, JR., LLC
7 WAKELEY ST FL 2, SEYMOUR, CT 06483-2819 • (203) 925-1800 • JURIS NO. 428309
BILLING INVOICE
LAW OFFICE OF V. MICHAEL SIMKO, JR., LLC
7 WAKELEY ST FL 2, SEYMOUR, CT 06483-2819 • (203) 925-1800 • JURIS NO. 428309
IMPORTANT NOTICES CONCERNING YOUR ADMISSION….
Western Connecticut
Health Network
Medical Record #i
Patient Name: _ Espinal, Ralph
)08:_ 1978-
----
IMPORTANT NOTICES CONCERNING YOUR OUTPATIENT TREATMENT; AGREEMENTS AND
ACKNOLWEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
Note: Please read this form. It provides important information about your treatment as an outpatient of the
Hospital. It also contains certain agreements in connection with your testing and/or treatment. In this form,
reference to the "patient" or "you" also means, as appropriate, the patient's personal representative or parent
where the patient is either a minor or is otherwise incapable of accepting or signing this form, and reference to
"Hospital(s)" means the hospital(s) within Western Connecticut Health Network ("WCHN") from which you are
receiving treatment or health care services, including Danbury Hospital (including its New Milford Hospital
campus) and/or Norwalk Hospital.
No Alterations: Failure to Sign & Financial Responsibility:
This form may not be altered by the patient in any manner. Please understand that we cannot track individual changes,
and therefore cannot honor cross-outs or new language. If you have questions about this form, please discuss them with
the Hospital staff, who will answer them to the best of their ability. Please also be aware that, if you do not sign this
authorization, and this results in a refusal of your insurance company, managed care organization or any other third
party payer to provide coverage and/or pay your Hospital bill, you will be personally responsible for the entire unpaid
portion of your bill.
Our Right to Examine You, Provide You with Routine Treatment and Care, and Perform Diagnostic Procedures,
Other Than Treatment, Care or Procedures Requiring Your Specific Informed Consent. By presenting yourself as
an outpatient, you are deemed to agree, without any specific written authorization by you , that we may perform routine
examinations, and provide treatment, which does not require a separate informed consent, under the general or specific
instructions or direction of your physician(s ) or Hospital Staff. As part of this general consent to medical procedures or
tests, you may be tested for human immunodeficiency virus ("HIV") or antibodies to HIV. However, such testing is
voluntary and you can chose not to be tested for HIV or antibodies to HIV if you so inform us. If medically appropriate,
your physician and/or Hospital staff may use various forms of photography such as digital imaging, standard
photography, and/or videotaping. Such photography is strictly limited to the purposes of diagnosis and treatment. The
use of photography for any other purpose, such as teaching or research , requires your specific consent I understand
and agree that any organs/tissues/cells removed from the patient become the property of the Hospital and may be
examined, retained, and/or used for medical, educational, and/or scientific research purposes, and/or subject to
disposal.
Informed Consent. If you require an operation or any procedure or treatment involving a degree of risk requiring an
informed consent, except in the event of emergency, your physician or another Hospital provider will discuss the risks,
benefits, and alternatives, answer your questions, and otherwise obtain your informed consent.
Students, Resident Physicians, Fellows and Researchers. Medical , nursing and other health care students , as well
as resident physicians (medical school graduates participating in post-graduate programs and training in a specialized
area of medicine) and fellows (physicians who have completed residency and are receiving additional training in a
specialized area of medicine) and medical researchers, provide or observe services provided to Hospital patients, and
may be present during and/or participate in my routine treatment, operations, and special procedures as part of their
research, or training and learning experiences.
Our Use and Disclosure of Your Protected Health Information for Treatment, Payment and Health Care
Operations, and for Other Lawful Purposes; Electronic Prescriptions . WCHN and the Hospital will keep your
health information confidential. There are a number of circumstances, however, where WCHN and the Hospital are
permitted to use and disclose medical records and other information about you and your health without your
authorization, including for the purposes of treatment, payment and health care operations, and there are other
circumstances where WCHN and the Hospital are required by law to use or disclose your health information. These
purposes are more specifically described in the WCHN Notice of Privacy Practices. The Hospitals utilize an electronic
prescription ("ePrescribe") system to facilitate your treatment. In using the ePrescribe system, the Hospitals and their
staff and/or your physician(s) will receive prescription history from third parties, such as other health care providers and
pharmacies, as well as submitting prescriptions. This information will support Hospital staff and/or your physician(s) in
avoiding drug duplication and drug interactions.
Communications Via Telephone. By providing a contact number to WCHN , I hereby authorize WCHN and the
Hospital(s), along with their respective employees, agents, and business associates, to contact me via land line, cellular
phone, and/or text message for any reason, including, without limitation, automated notifications, appointment
reminders, and collections. You are not required to agree to this section in order to receive services from WCHN.
Our Use and Disclosure of Your Protected Health Information for Treatment, Payment and Health Care
Operations, and for Other Lawful Purposes: Electronic Prescriptions. State law and HIPAA require that the release
of health information be specifically authorized by the patient in certain circumstances. In addition, certain disclosures of
records and communications concerning psychiatric conditions, substance abuse, genetic testing, and HIV-related
D 83203 Rev 1/19
6504
Espinal, Ralph
Western Connecticut
Health Network
OAl'\f>uty ►\°'IYll N~'w'•41fftotO-..OtfS' la•tl0t1111,6H&-.f r.11
testing and treatment are subject to special authorization requirements under state law. Finally, if you were treated on
an outpatient basis in our dual diagnosis program, federal law also has certain special authorization requirements. This
section is your authorization to release such health information to specific persons/entities for the purposes identified
below.
I authorize the Hospital(s) to release all records of and information about treatment in the Hospital's psychiatric unit
(including treatment where there is a dual diagnosis of substance abuse), or outpatient records of treatment for
substance abuse (which are referred to collectively in this authorization as "Confidential Information") to the following
persons/entities for the stated purposes:
third-party payors (which for purposes of this authorization includes insurance companies, managed care
organizations, and Medicare or Medicaid and other governmental payors), hospital agents or governmental
agencies for purposes of payment of my bill.
any utilization, managed care, and/or quality review organization affiliated with my insurance company/managed
care organization (as defined above) for purposes of utilization management and quality review and/or
improvement.
other health providers for the purpose of providing continuing care or for their health care operations.
state or federal agencies or accreditation bodies for auditing, licensure/regulatory, and/or accreditation
purposes.
I also authorize the disclosure to the Hospital of Confidential Information that may be in the possession of any of my
physicians for the same purposes. I have been informed that my refusal to authorize the release of Confidential
Information will not jeopardize my right to obtain present or future treatment except where disclosure or use of the
information is necessary for treatment. I understand that I may withdraw my authorization to release Confidential
Information at any time in writing, except to the extent that action already has been taken in reliance on such
authorization. This authorization expires three years from the patient's last date of treatment as an outpatient.
Physicians are Independent Contractors Responsible for the Patient's Care._Your physicians are not employees of
the Hospital. While each Hospital periodically reviews the credentials of all of physicians on its Medical Staff, your
physicians, not the Hospital, are responsible for the care that they provide to you while you are an outpatient. They, and
not the Hospital, are responsible for obtaining your informed consent to operations, procedures or treatments when it is
required. If you have any questions for your physicians, including questions about the nature or risks and benefits of or
the alternatives to any intended operation, procedure or treatment, or questions about the physician's charges or bills,
you should address those questions to your physician since he/she is solely responsible for answering such questions.
The physician bill for professional services is separate from the Hospital's facility bill; therefore you may receive two bills ,
or more if additional physicians are involved in your care at the Hospital.
Right to Receive a Copy of Hospital Charges. Upon request, patients may receive copies of their Hospital charges.
A Patient Financial Services Representative is available at (203) 730-5800 for Danbury Hospital and at (203) 852- 2016
for Norwalk Hospital should assistance be needed.
Patients' Rights and Responsibilities. If you are an inpatient, the Hospital's Policy on Patient Rights and
Responsibilities has been provided to you; if you are an outpatient, it is available upon request. All patients are admitted
or treated on condition that they comply with their responsibilities to cooperate with the Hospital and to respect the rights
of other patients, visitors, and Hospital staff, and to leave the Hospital promptly when medically cleared to do so. Among
other things, you are required to assist in the control of noise, smoking, and the number and behavior of visitors, and
neither you nor any of your visitors may photograph, videotape, record, broadcast or livestream conversations other
patients or staff members. Patients are not permitted to bring weapons into the Hospital and you may be searched.
YOUR AGREEMENTS IN ORDER TO BE TREATED
Assignment of Benefits - Authorization to Third Party Payment Sources to Make Payments Directly to the
Hospital. I authorize third party payors (which for purposes of this form include insurance companies, managed care
organizations , Medicare, Medicaid and other governmental payors , and employer-sponsored health benefit plans), to
make payment directly to the Hospital, its affiliates, and any physicians involved in my care for medical services that it
provides to me/the patient, and assign to the Hospital any/all medical benefits (Group or Direct) otherwise payable to
me/the patient. I understand and agree that I am financially responsible for payment of (i) all co-payments, co-insurance,
and deductibles, (ii) all medical services provided by the Hospital that are not covered by such payors, and (iii) all costs
of collection of any delinquent balance, including but not limited to reasonable attorneys' fees, which may be added to
my/the patient's account. Without limitation of the foregoing sentence, I understand and agree that if the Hospital does
not have a participating provider agreement or other contract directly with my/the patient's third party payor(s), then by
accepting this authorization, the Hospital is not agreeing to accept the reimbursement payable by such payor(s) as
payment in full for the medical services it provides to me/the patient; the Hospital retains the right to balance bill me for
the difference between its charges for its services and the amount actually paid to the Hospital by such payor(s) for such
services, and I agree to be responsible for that amount. No provision of any of my payors' Plan Documents that is
intended or could be deemed to waive, or otherwise prevent or limit, the Hospital's right to balance bill me will be binding
on the Hospital. I further understand and agree that neither the Hospital's negotiation, endorsement or deposit of a
D 83203 Rev 1/19
2
~1 Western Connecticut
'- Health Network
OSW'!butvHQap,rol NOWlofrlford~ Nol'w.'.IJlr:~pit.al
check from me/the patient or any of my/the patient's payers that is marked "Payment in full " (or anything similar), nor the
Hospital's receipt of an Explanation of Benefits (EOB) that states "Payment in full" (or anything similar), will be deemed
an "accord and satisfaction." I understand and agree that my/the patient's refusal to grant authorization to my third party
payers will in no way jeopardize my/the patient's right to obtain present or future treatment except where disclosure is
necessary for treatment, but understand and agree that under such circumstances I will be responsible for paying
my/the patient's bill in full.
Personal Valuables. If you are staying overnight in the Hospital, The Hospital maintains a safe for the safekeeping of
money and valuables. If you choose not to place valuables in the Hospital safe, the Hospital will not be responsible for
the loss of or damage to your valuables. The Hospital shall not be responsible for loss or damage to items including
documents, cash , dental work/dental prosthetics, eyeglasses, credit cards, hearing aids and items of unusual value or
size that have not or cannot be placed in the Hospital safe. Any personal valuables should be given to a family member
or friend for safekeeping.
Veterans. Based on HB 5294, An Act Concerning the Admission of Veterans, the Hospital is required to inquire whether
you are, or your spouse is, a veteran of the US Armed Forces. Please indicate if you or your spouse is a veteran of the
US Armed Forces. State the name of your spouse if he/she is a veteran. Please identify the branch of the Armed
Forces and state the approximate dates of service:
PATIENT RIGHTS AND RESPONSIBILITIES AND NOTICE OF PRIVACY PRACTICES
I acknowledge that the Hospital's Policy on Patient Rights and Responsibilities is posted and is available to me. I agree
to comply with this Policy. I acknowledge that I have received a copy of WCHN's Notice of Privacy Practices. If I only
had testing by WCHN that was requested by my physician, and I did not personally present at any WCHN site (includi ng
any Hospital) for treatment, I acknowledge that I have a right to request and be provided with a copy of the Notice of
Privacy Practices.
I HAVE READ AND UNDERSTAND THE AUTHORIZATIONS, AGREEMENTS AND NOTICES SET FORTH IN THIS
FORM, AND AGREE TO SUCH AUTHORIZATIONS, AGREEMENTS AND NOTICES.
Date: 4/23/2021 . 8:1 2:30 AM
T1me:_ _ _ __
s·1gnature:_.... M . . . . . . . . . . . .. .. . . ..._ __ _ _ __ _
Witness: Cruz, Sandra (NMH) . h. Registrar/Tech
Rea
I t ions 1p:
If this form has not been signed by the patient, please specify the signer's relationship to the patient, and , if necessary,
explain why the patient did not sign. If signed by the Patient's Representative, please print name and describe
relationship to patient.
Name: Relationship:
COMPLETE THE FOLLOWING DOCUMENTATION OF GOOD FAITH EFFORTS IF IT IS NOT POSSIBLE TO
OBTAIN A SIGNATURE:
The following good faith efforts were made to obtain a signature:
A signature could not be obtained for the following reasons: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Documented by: Signature _ _ _ _ _ _ _ __ Print Name_
Date Time
D 83203 Rev 1/19
3
Preview
LAW OFFICE OF V. MICHAEL SIMKO, JR., LLC 7 WAKELEY ST FL 2, SEYMOUR, CT 06483-2819 • (203) 925-1800 • JURIS NO. 428309 BILLING INVOICE LAW OFFICE OF V. MICHAEL SIMKO, JR., LLC 7 WAKELEY ST FL 2, SEYMOUR, CT 06483-2819 • (203) 925-1800 • JURIS NO. 428309 IMPORTANT NOTICES CONCERNING YOUR ADMISSION…. Western Connecticut Health Network Medical Record #i Patient Name: _ Espinal, Ralph )08:_ 1978- ---- IMPORTANT NOTICES CONCERNING YOUR OUTPATIENT TREATMENT; AGREEMENTS AND ACKNOLWEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES Note: Please read this form. It provides important information about your treatment as an outpatient of the Hospital. It also contains certain agreements in connection with your testing and/or treatment. In this form, reference to the "patient" or "you" also means, as appropriate, the patient's personal representative or parent where the patient is either a minor or is otherwise incapable of accepting or signing this form, and reference to "Hospital(s)" means the hospital(s) within Western Connecticut Health Network ("WCHN") from which you are receiving treatment or health care services, including Danbury Hospital (including its New Milford Hospital campus) and/or Norwalk Hospital. No Alterations: Failure to Sign & Financial Responsibility: This form may not be altered by the patient in any manner. Please understand that we cannot track individual changes, and therefore cannot honor cross-outs or new language. If you have questions about this form, please discuss them with the Hospital staff, who will answer them to the best of their ability. Please also be aware that, if you do not sign this authorization, and this results in a refusal of your insurance company, managed care organization or any other third party payer to provide coverage and/or pay your Hospital bill, you will be personally responsible for the entire unpaid portion of your bill. Our Right to Examine You, Provide You with Routine Treatment and Care, and Perform Diagnostic Procedures, Other Than Treatment, Care or Procedures Requiring Your Specific Informed Consent. By presenting yourself as an outpatient, you are deemed to agree, without any specific written authorization by you , that we may perform routine examinations, and provide treatment, which does not require a separate informed consent, under the general or specific instructions or direction of your physician(s ) or Hospital Staff. As part of this general consent to medical procedures or tests, you may be tested for human immunodeficiency virus ("HIV") or antibodies to HIV. However, such testing is voluntary and you can chose not to be tested for HIV or antibodies to HIV if you so inform us. If medically appropriate, your physician and/or Hospital staff may use various forms of photography such as digital imaging, standard photography, and/or videotaping. Such photography is strictly limited to the purposes of diagnosis and treatment. The use of photography for any other purpose, such as teaching or research , requires your specific consent I understand and agree that any organs/tissues/cells removed from the patient become the property of the Hospital and may be examined, retained, and/or used for medical, educational, and/or scientific research purposes, and/or subject to disposal. Informed Consent. If you require an operation or any procedure or treatment involving a degree of risk requiring an informed consent, except in the event of emergency, your physician or another Hospital provider will discuss the risks, benefits, and alternatives, answer your questions, and otherwise obtain your informed consent. Students, Resident Physicians, Fellows and Researchers. Medical , nursing and other health care students , as well as resident physicians (medical school graduates participating in post-graduate programs and training in a specialized area of medicine) and fellows (physicians who have completed residency and are receiving additional training in a specialized area of medicine) and medical researchers, provide or observe services provided to Hospital patients, and may be present during and/or participate in my routine treatment, operations, and special procedures as part of their research, or training and learning experiences. Our Use and Disclosure of Your Protected Health Information for Treatment, Payment and Health Care Operations, and for Other Lawful Purposes; Electronic Prescriptions . WCHN and the Hospital will keep your health information confidential. There are a number of circumstances, however, where WCHN and the Hospital are permitted to use and disclose medical records and other information about you and your health without your authorization, including for the purposes of treatment, payment and health care operations, and there are other circumstances where WCHN and the Hospital are required by law to use or disclose your health information. These purposes are more specifically described in the WCHN Notice of Privacy Practices. The Hospitals utilize an electronic prescription ("ePrescribe") system to facilitate your treatment. In using the ePrescribe system, the Hospitals and their staff and/or your physician(s) will receive prescription history from third parties, such as other health care providers and pharmacies, as well as submitting prescriptions. This information will support Hospital staff and/or your physician(s) in avoiding drug duplication and drug interactions. Communications Via Telephone. By providing a contact number to WCHN , I hereby authorize WCHN and the Hospital(s), along with their respective employees, agents, and business associates, to contact me via land line, cellular phone, and/or text message for any reason, including, without limitation, automated notifications, appointment reminders, and collections. You are not required to agree to this section in order to receive services from WCHN. Our Use and Disclosure of Your Protected Health Information for Treatment, Payment and Health Care Operations, and for Other Lawful Purposes: Electronic Prescriptions. State law and HIPAA require that the release of health information be specifically authorized by the patient in certain circumstances. In addition, certain disclosures of records and communications concerning psychiatric conditions, substance abuse, genetic testing, and HIV-related D 83203 Rev 1/19 6504 Espinal, Ralph Western Connecticut Health Network OAl'\f>uty ►\°'IYll N~'w'•41fftotO-..OtfS' la•tl0t1111,6H&-.f r.11 testing and treatment are subject to special authorization requirements under state law. Finally, if you were treated on an outpatient basis in our dual diagnosis program, federal law also has certain special authorization requirements. This section is your authorization to release such health information to specific persons/entities for the purposes identified below. I authorize the Hospital(s) to release all records of and information about treatment in the Hospital's psychiatric unit (including treatment where there is a dual diagnosis of substance abuse), or outpatient records of treatment for substance abuse (which are referred to collectively in this authorization as "Confidential Information") to the following persons/entities for the stated purposes: third-party payors (which for purposes of this authorization includes insurance companies, managed care organizations, and Medicare or Medicaid and other governmental payors), hospital agents or governmental agencies for purposes of payment of my bill. any utilization, managed care, and/or quality review organization affiliated with my insurance company/managed care organization (as defined above) for purposes of utilization management and quality review and/or improvement. other health providers for the purpose of providing continuing care or for their health care operations. state or federal agencies or accreditation bodies for auditing, licensure/regulatory, and/or accreditation purposes. I also authorize the disclosure to the Hospital of Confidential Information that may be in the possession of any of my physicians for the same purposes. I have been informed that my refusal to authorize the release of Confidential Information will not jeopardize my right to obtain present or future treatment except where disclosure or use of the information is necessary for treatment. I understand that I may withdraw my authorization to release Confidential Information at any time in writing, except to the extent that action already has been taken in reliance on such authorization. This authorization expires three years from the patient's last date of treatment as an outpatient. Physicians are Independent Contractors Responsible for the Patient's Care._Your physicians are not employees of the Hospital. While each Hospital periodically reviews the credentials of all of physicians on its Medical Staff, your physicians, not the Hospital, are responsible for the care that they provide to you while you are an outpatient. They, and not the Hospital, are responsible for obtaining your informed consent to operations, procedures or treatments when it is required. If you have any questions for your physicians, including questions about the nature or risks and benefits of or the alternatives to any intended operation, procedure or treatment, or questions about the physician's charges or bills, you should address those questions to your physician since he/she is solely responsible for answering such questions. The physician bill for professional services is separate from the Hospital's facility bill; therefore you may receive two bills , or more if additional physicians are involved in your care at the Hospital. Right to Receive a Copy of Hospital Charges. Upon request, patients may receive copies of their Hospital charges. A Patient Financial Services Representative is available at (203) 730-5800 for Danbury Hospital and at (203) 852- 2016 for Norwalk Hospital should assistance be needed. Patients' Rights and Responsibilities. If you are an inpatient, the Hospital's Policy on Patient Rights and Responsibilities has been provided to you; if you are an outpatient, it is available upon request. All patients are admitted or treated on condition that they comply with their responsibilities to cooperate with the Hospital and to respect the rights of other patients, visitors, and Hospital staff, and to leave the Hospital promptly when medically cleared to do so. Among other things, you are required to assist in the control of noise, smoking, and the number and behavior of visitors, and neither you nor any of your visitors may photograph, videotape, record, broadcast or livestream conversations other patients or staff members. Patients are not permitted to bring weapons into the Hospital and you may be searched. YOUR AGREEMENTS IN ORDER TO BE TREATED Assignment of Benefits - Authorization to Third Party Payment Sources to Make Payments Directly to the Hospital. I authorize third party payors (which for purposes of this form include insurance companies, managed care organizations , Medicare, Medicaid and other governmental payors , and employer-sponsored health benefit plans), to make payment directly to the Hospital, its affiliates, and any physicians involved in my care for medical services that it provides to me/the patient, and assign to the Hospital any/all medical benefits (Group or Direct) otherwise payable to me/the patient. I understand and agree that I am financially responsible for payment of (i) all co-payments, co-insurance, and deductibles, (ii) all medical services provided by the Hospital that are not covered by such payors, and (iii) all costs of collection of any delinquent balance, including but not limited to reasonable attorneys' fees, which may be added to my/the patient's account. Without limitation of the foregoing sentence, I understand and agree that if the Hospital does not have a participating provider agreement or other contract directly with my/the patient's third party payor(s), then by accepting this authorization, the Hospital is not agreeing to accept the reimbursement payable by such payor(s) as payment in full for the medical services it provides to me/the patient; the Hospital retains the right to balance bill me for the difference between its charges for its services and the amount actually paid to the Hospital by such payor(s) for such services, and I agree to be responsible for that amount. No provision of any of my payors' Plan Documents that is intended or could be deemed to waive, or otherwise prevent or limit, the Hospital's right to balance bill me will be binding on the Hospital. I further understand and agree that neither the Hospital's negotiation, endorsement or deposit of a D 83203 Rev 1/19 2 ~1 Western Connecticut '- Health Network OSW'!butvHQap,rol NOWlofrlford~ Nol'w.'.IJlr:~pit.al check from me/the patient or any of my/the patient's payers that is marked "Payment in full " (or anything similar), nor the Hospital's receipt of an Explanation of Benefits (EOB) that states "Payment in full" (or anything similar), will be deemed an "accord and satisfaction." I understand and agree that my/the patient's refusal to grant authorization to my third party payers will in no way jeopardize my/the patient's right to obtain present or future treatment except where disclosure is necessary for treatment, but understand and agree that under such circumstances I will be responsible for paying my/the patient's bill in full. Personal Valuables. If you are staying overnight in the Hospital, The Hospital maintains a safe for the safekeeping of money and valuables. If you choose not to place valuables in the Hospital safe, the Hospital will not be responsible for the loss of or damage to your valuables. The Hospital shall not be responsible for loss or damage to items including documents, cash , dental work/dental prosthetics, eyeglasses, credit cards, hearing aids and items of unusual value or size that have not or cannot be placed in the Hospital safe. Any personal valuables should be given to a family member or friend for safekeeping. Veterans. Based on HB 5294, An Act Concerning the Admission of Veterans, the Hospital is required to inquire whether you are, or your spouse is, a veteran of the US Armed Forces. Please indicate if you or your spouse is a veteran of the US Armed Forces. State the name of your spouse if he/she is a veteran. Please identify the branch of the Armed Forces and state the approximate dates of service: PATIENT RIGHTS AND RESPONSIBILITIES AND NOTICE OF PRIVACY PRACTICES I acknowledge that the Hospital's Policy on Patient Rights and Responsibilities is posted and is available to me. I agree to comply with this Policy. I acknowledge that I have received a copy of WCHN's Notice of Privacy Practices. If I only had testing by WCHN that was requested by my physician, and I did not personally present at any WCHN site (includi ng any Hospital) for treatment, I acknowledge that I have a right to request and be provided with a copy of the Notice of Privacy Practices. I HAVE READ AND UNDERSTAND THE AUTHORIZATIONS, AGREEMENTS AND NOTICES SET FORTH IN THIS FORM, AND AGREE TO SUCH AUTHORIZATIONS, AGREEMENTS AND NOTICES. Date: 4/23/2021 . 8:1 2:30 AM T1me:_ _ _ __ s·1gnature:_.... M . . . . . . . . . . . .. .. . . ..._ __ _ _ __ _ Witness: Cruz, Sandra (NMH) . h. Registrar/Tech Rea I t ions 1p: If this form has not been signed by the patient, please specify the signer's relationship to the patient, and , if necessary, explain why the patient did not sign. If signed by the Patient's Representative, please print name and describe relationship to patient. Name: Relationship: COMPLETE THE FOLLOWING DOCUMENTATION OF GOOD FAITH EFFORTS IF IT IS NOT POSSIBLE TO OBTAIN A SIGNATURE: The following good faith efforts were made to obtain a signature: A signature could not be obtained for the following reasons: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Documented by: Signature _ _ _ _ _ _ _ __ Print Name_ Date Time D 83203 Rev 1/19 3