General Consents
Acknowledgement of Required No�ces
Advance Direc�ves Atesta�on
Pa�ent Name: ___________________ Date of Birth : _____________ Medical Record #: ____________
NOTICE OF NONDISCRIMINATION
Avenues Recovery Medical Center at Valley Forge (herein referred to as Valley Forge Medical Center & Hospital or
VFMC) complies with applicable state and federal civil rights laws and does not discrimina�on on the basis of race,
color, na�onal origin, age, disability, or sex. VFMC does not exclude people or treat them differently because of
race, color, na�onal origin, age, disability, or sex or any other basis prohibited by law. VFMC will not tolerate
discrimina�on against my provider, other healthcare professions or staff because of race, color, gender, na�onal
origin, age, disability, sex, or any other basis prohibited by federal, state, or local law.
GENERAL CONSENT FOR CARE AND TREATMENT
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I have the right, as a pa�ent, to be informed about my condi�on and the recommended surgical, medical
or diagnos�c procedure to be used so that I may make the decision whether or not to undergo any
suggested treatment or procedure a�er knowing the risks and hazards involved. At this point in my care,
no specific treatment plan has been recommended. This consent form is simply an effort to obtain your
permission to perform the evalua�on necessary to iden�fy the appropriate treatment and/or procedure
for any iden�fied condi�on(s).
I agree to examina�on and treatment by providers, residents, students, and other healthcare
professionals at VFMC. This may include in-person shared medical appointments, telemedicine,
videotaping, photographic, and audio devices. These tools may be used to treat/diagnose or for
procedures to be performed for medical, scien�fic, and/or personal safety.
I understand that if addi�onal tes�ng, invasive or interven�onal procedures are recommended, I may be
asked to read and sign addi�onal consent forms prior to the test(s) or procedure(s). I cer�fy that I have
read and fully understand the above statements and consent fully and voluntarily to its contents.
By providing my consent, I am indica�ng that:
I intend that this consent is con�nuing in nature even a�er a specific diagnosis has been made and
treatment recommended.
I consent to treatment at this facility or other facility under common ownership.
I have the right at any �me to discon�nue services. I have the right to discuss the treatment plan with my
physician about the purpose, poten�al risks and benefits of any test ordered for me.
If I have any concerns regarding any test or treatment recommend by my health care provider, I am
encouraged to ask ques�ons. I voluntarily request a physician, and/or mid-level provider (nurse
prac��oner, physician assistant, or clinical nurse specialist), and other health care providers or the
designees as deemed necessary, to perform reasonable and necessary medical examina�on, tes�ng and
treatment for the condi�on which has brought me to seek care at VFMC.
If I am par�cipated in a shared medical appointment, I will atend this appointment with other pa�ents.
During these appointments, personal informa�on about me may be shared by my provider to others.
The provider may obtain specimens of my blood, urine, and other bodily fluids/�ssues (“specimens”). I
authorize the provider to retain and preserve these specimens for scien�fic and teaching purposes as well
as perform other tests not related to my diagnosis on these specimens. The provider may dispose of these
specimens as it chooses.
I am aware the prac�ce of medicine and surgery is not an exact scient. No one has made any promises or
guarantees to me about the results of my treatment, care, or examina�on at VFMC.
I understand that “providers” include, but are not limited to, physicians and other healthcare providers
that are my trea�ng and consul�ng physicians, Emergency Department physicians, radiologists,
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General Consents
Acknowledgement of Required No�ces
Advance Direc�ves Atesta�on
Pa�ent Name: ___________________ Date of Birth : _____________ Medical Record #: ____________
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anesthesiologists, other specialists and any allied healthcare providers whom these physicians employ.
Some of the physicians and their allied healthcare providers are independent medical prac��oners who
are not employees or agents of VFMC, but who are permited to use VFMC hospital facili�es for the care
and treatment of their pa�ents. VFMC does not control or direct a physician’s care of their pa�ents.
Pennsylvania law allows healthcare providers to test my blood for HIV (AIDS virus) or Hepa��s without my
consent if someone who has helped in my care is exposed to my blood or body fluids
Should my condi�on require referral to a specialist, I understand I will be asked my choice of a provider. I
will have the opportunity to have VFMC contact the provider of my choice or if I do not have a preference,
an independent provider from VFMC “on-call” list will be called. I consent to my insurance company billing
for professional services given by this provider whether or not this provider par�cipates in my insurance
program.
CONSENT TO TREATMENT USING TELEMEDICINE
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I consent to treatment involving the use of electronic communica�ons to enable health care providers at
different loca�ons to share my individual pa�ent medical informa�on for diagnosis, therapy, follow-up,
and/or educa�on purposes.
I consent to forwarding my informa�on to a third party as needed to receive telemedicine services, and I
understand that exis�ng confiden�ality protec�ons apply.
I acknowledge that while telemedicine can be used to provide improved access to medical care, as with
any medical procedure, there are poten�al risks and no results can be guaranteed or assured.
These risks include, but are not limited to: technical problems with the informa�on transmission;
equipment failures that could result in lost informa�on or delays in treatment.
I understand that I have a right to withhold or withdraw my consent to the use of telemedicine in the
course of my care at any �me, without affec�ng my right to future treatment and without risking the loss
or withdrawal of any program benefits to which I would otherwise be en�tled.
RELEASE OF PROTECTED HEALTH INFORMATION
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VFMC’s No�ce of Privacy Prac�ces provides informa�on about how we may use or disclose protected
health informa�on. The no�ce contains a pa�ent’s rights sec�on describing my rights under the law. By
signing this consent, I acknowledge that I have had the opportunity to receive a copy of the No�ce of
Privacy Prac�ces and have had an opportunity to ask ques�ons about the informa�on in the No�ce.
My health informa�on includes diagnos�c informa�on, lab tests, medica�ons, allergies, history and
assessment, treatment plans, progress or presence in treatment, clinical notes, discharge summaries and
other records pertaining to my treatment. This consent specifically includes informa�on concerning
psychological condi�ons, psychiatric condi�ons, intellectual disability condi�ons, gene�c informa�on,
chemical dependency condi�ons and/or infec�ous diseases including, but not limited to, blood borne
diseases, such as HIV and AIDS.
VFMC may release my medical informa�on to:
o Insurance companies, health plans and administrators for payment of services I receive
o Government agencies like Medicare and Medicaid or as required by law
o My providers and others involved in my care now or in the future
o My employer, if the records are related to care or serviced pay for by my employer, or for other
purposes that are allowed under law
o Any person or en�ty responsible to pay all or part of my bill
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General Consents
Acknowledgement of Required No�ces
Advance Direc�ves Atesta�on
Pa�ent Name: ___________________ Date of Birth : _____________ Medical Record #: ____________
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I hereby permit VFMC and the physicians or other health professionals involved in the inpa�ent or
outpa�ent care to release healthcare informa�on for purposes of treatment, payment, or healthcare
opera�ons. Healthcare informa�on regarding a prior service(s) at other VFMC affiliated providers may be
made available to subsequent VFMC-affiliated providers to coordinate care. Healthcare informa�on may
be released to any person or en�ty liable for payment on the Pa�ent’s behalf in order to verify coverage or
payment ques�ons, or for any other purpose related to benefit payment.
Healthcare informa�on may also be released to my employer’s designee when the services delivered are
related to a claim under worker’s compensa�on.
If I am covered by Medicare or Medicaid, I authorize the release of healthcare informa�on to the Social
Security Administra�on or its intermediaries or carriers for payment of a Medicare claim or to the
appropriate state agency for payment of a Medicaid claim. This informa�on may include, without
limita�on, history and physical, emergency records, laboratory reports, opera�ve reports, physician
progress notes, nurse’s notes, consulta�ons, psychological and/or psychiatric reports, drug and alcohol
treatment and discharge summary.
I agree that VFMC can take my picture and save it to my electronic medical record. I understand that VFMC
will use this picture for iden�fica�on purpose with the goal of improving pa�ent experience.
By signing this form, I consent to our use and disclosure of my protected healthcare informa�on and
poten�ally anonymous usage in a publica�on. I have the right to revoke this consent in wri�ng. However,
such a revoca�on will not be retroac�ve.
I agree that the consents and permissions as described in this consent apply to all my sensi�ve health
informa�on in VFMC’s possession, including informa�on concerning care received prior to or a�er the
date of this form. I understand that I may withdraw my consent by providing writen no�ce to VFMC at the
addresses provided in the VFMC No�ce of Privacy Prac�ces.
If I withdraw my consent, my withdrawal will not apply to any uses and releases of my health informa�on
already made by VFMC before I changed my consent choice or, other than described above, to any health
informa�on that has become part of my record before I changed my consent choice. I understand that I
have the right to inspect and copy any of my sensi�ve health informa�on to be used or disclosed.
DISCLOSURES TO FRIENDS AND/OR FAMILY MEMBERS
I may give permission for my Protected Health Informa�on to be disclosed for purposes of communica�ng results,
findings and care decisions to the family members and others. I will communicate the Name, Rela�onship, and
contact informa�on to the clinical team to ensure it is documented.
RELEASE OF RESPONSIBILITY FOR PERSONAL VALUABLES
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I understand that VFMC will not be responsible for the loss, destruc�on or the� of any personal property
that I bring with me to VFMC. I take full responsibility—and release VFMC from responsibility and
liability—for my personal property.
I am aware that despite the best efforts of VFMC to ensure the security of my personal items, VFMC
cannot accept responsibility for loss or damage to you property. This includes any items le� in my hospital
room or in storage at our campus safety facili�es.
Further, VFMC’s liability for any loss, damage, or threat is limited to the maximum extent permited by law,
and VFMC will not be responsible for any indirect or consequen�al damages.
The Hospital cannot be responsible for items held longer than thirty (30) days a�er discharge.
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General Consents
Acknowledgement of Required No�ces
Advance Direc�ves Atesta�on
Pa�ent Name: ___________________ Date of Birth : _____________ Medical Record #: ____________
CONSENT TO CONTACT
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I have given residen�al and/or cellular telephone numbers and an email address to VFMC. I consent to
receive autodialed and/or pre-recorded telephone calls, text messages, and/or emails from VFMC and/or
its agents/third par�es. These communica�ons may include billing. I am responsible for any
communica�on charges from my phone provider(s). This authoriza�on is voluntary. I can s�ll be treated
even if I do not give “consent to contact”.
I authorize VFMC to send unencrypted text messages to the cell phone I have on file in my VFMC medical
record. I understand that:
o Text messages are unencrypted. Health Informa�on sent in an unencrypted text message may be
intercepted and seen by others. There are other risks with unencrypted text message including
misdirected texts, messages forwarded to others, and messages that are stored on services that
may no security. By choosing to receive your Health Informa�on by unencrypted text, you are
acknowledging and accep�ng these risks.
o This Authoriza�on is valid un�l I revoke and withdraw my permission or receive text messages.
o I may revoke or withdraw this Authoriza�on, except to the extent that ac�on has been taken prior
to the receipt of the revoca�on or withdrawal, at my providers office or by calling:
I agree that, in order for VFMC, or Extended Business Office (EBO) Servicers and collec�on agents, to
service my account or to collect any amounts I may owe, I expressly agree and consent that the prac�ce or
EBO Servicer and collec�on agents may contact me by telephone at any telephone number, without
limita�on of wireless, I have provided or the prac�ce or EBO Servicer and collec�on agents have obtained
or, at any phone number forwarded or transferred from that number, regarding the services rendered, or
my related financial obliga�ons. Methods of contact may include using pre-recorded/ar�ficial voice
messages and/or use of an automa�c dialing device, as applicable.
ADVANCE DIRECTIVES
Valley Forge Medical Center and Hospital (VFMC) respects and encourages pa�ent self-determina�on regarding
medical treatment, o�en including a living will. Pa�ents will be encouraged and assisted to be ac�ve par�cipants in
the decision-making process regarding their care through educa�on, inquiry, and assistance as requested. VFMC
will not condi�on the provision of care or otherwise discriminate against individuals based on whether the
individual has executed a Medical Advance Direc�ve.
PATIENT RIGHTS AND RESPONSIBILITIES
By signing this form, I acknowledge that I have been offered the opportunity to review and receive a copy of
VFMC’s Pa�ent Rights and Responsibili�es and the informa�on contained therein, and I have had an opportunity to
ask ques�ons about the informa�on in the Pa�ent Rights and Responsibili�es.
TRANSLATION
I understand I can access this document in other languages upon request.
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General Consents
Acknowledgement of Required No�ces
Advance Direc�ves Atesta�on
Pa�ent Name: ___________________ Date of Birth : _____________ Medical Record #: ____________
CERTIFICATION
I have read, understand and agree to the tenants of the consent in this form. I have been given the opportunity to
ask ques�ons and I have no remaining ques�ons at this �me. I understand where I can access addi�onal
informa�on. I cer�fy that to the best of my knowledge and belief the informa�on provided is complete and correct.
In understand that this consent subject to revoca�on by me at any �me except if the person or en�ty authorized to
make a disclosure has already acted in reliance on the form. This consent is valid for one (1) year from the date of
my signature or un�l revoked in wri�ng.
I hereby acknowledge that I have read, understand, and agree to the following consents and that I
have been given the opportunity to ask ques�ons:
General Consent for Care and Treatment
Release of Protected Health Informa�on
Release of Responsibility for Personal Valuables
Consent to Contact
I hereby acknowledge that I have been offered a copy of the following documents and this informa�on
has been discussed with me:
No�ce of Privacy Prac�ces
Pa�ent Rights & Responsibili�es
A Guide to Advance Direc�ves
I understand that a copy of my advance direc�ve must be provided to VFMC to ensure that my
advance direc�ves are followed. I atest:
Yes, I have an advance direc�ve and I have provided a copy of my advance direc�ve(s) to
VFMC to be placed on file
No, I do not have an advance direc�ve.
Refusal to Acknowledge
If pa�ent refused or was unable to acknowledge the no�ces provided in this form, please explain what
efforts were made to obtain acknowledgement and reason for refusal:
A copy of this form as been offered to me:
Accepted
Pa�ent Signature
Date
Witness Signature
Date
Declined
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