Note: As a rural level 4 Trauma Facility, our physicians are local physicians on call for Emergencies in the ER. This facility does not have a physician in house at all times. Because of this, you may not be seen for several hours if you do not have a life threatening or acute emergent condition. You will be triaged and monitored by our Nursing staff until seen by the physician.


  1. CONSENT FOR MEDICAL TREATMENT: I hereby voluntarily consent to health care for diagnostic procedures, labs, medical or x-ray treatment and medication by the staff and/or employees of Plains Memorial Hospital and the health care providers involved in my care, his/her assistants or designees including residents/medical students as are necessary and appropriate in his/her judgement. The undersigned further recognizes that the diagnostic procedures, medical or x-ray treatment and medication provided to the patient are rendered under the general and special instructions of the patient's attending physician or other attending health care provider. This consent for medical treatment has been fully explained to me and I certify that I understand its content and that all questions have been asked and answered to my satisfaction. I also acknowledge that I have received a copy of this form.

  2. ASSIGNMENT OF INSURANCE BENEFITS: In consideration of hospital services received or to be received, I irrevocably assign to Plains Memorial Hospital for application on patient's bill all benefits of any type whatsoever arising out of any policy of insurance, self-insurance or otherwise, insuring patient or any other party liable to patient. It is agreed that such assignment shall not exceed the total of hospital charges and that such payment shall discharge the said insurance company or other person of any and all obligations under the policy to the extent of such payment. Unless otherwise provided by law or separate written agreement of the Hospital, the undersigned and the patient, who shall be jointly and severally responsible for the portion of the patient's bill that is not covered by the benefits so assigned, hereby guarantee payment of any kind and all hospital charges not covered by this assignment and waive any and all notices and demands in the event of non-payment.

  3. MEDICARE PATIENT'S RECORD OF SIGNATURE, PATIENT'S CERTIFICATION, AUTHORIZATION TO RELEASE INFORMATION AND PAYMENT REQUEST: I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or the information about me to release to the Social Security Administration, Centers for Medicare or Medicaid Services (CMS), or its intermediaries or carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. I also hereby authorize my signature to this document to be maintained on file by Plains Memorial Hospital as part of the permanent record.

  4. WRITTEN ACKNOWLEDGEMENT OF PRIVACY PRACTICES: I acknowledge that I have received a copy of Plains Memorial Hospital's Notice of Privacy Practices, which sets forth the ways in which my medical record information can be used or disclosed by Plains Memorial Hospital and which outlines my rights to this information.

  5. NOTICE OF INDEPENDENT CONTRACTOR STATUS OF PHYSICIANS AND OTHER HEALTH CARE PROVIDERS: Plains Memorial Hospital is not responsible for the act, omission, diagnosis, or care rendered by physicians and other health care providers appointed to its medical staff such as podiatrists, dentists, and psychologists, each of whom is furnishing services to Hospital patients as an independent contractor and not as an employee or agent of the Hospital. This includes your personal physician, radiologist, pathologist, anesthesia practitioners, emergency department physician(s), and other physicians and surgeons, each of whom are not directed or controlled by the Hospital.

  6. NO GUARANTEES, SIGNING OUT AGAINST MEDICAL ADVICE: I understand that there are no guarantees made concerning the results of my care. I am aware that the practice of medicine and surgery is not an exact science. Upon dismissal, I agree to follow the discharge instructions provided me and to follow-up with the physician, health care practitioner, or institution for continued medical treatment and care as directed. If I refuse treatment that is suggested for me, or if I leave the Hospital against medical advice, I will not hold the Hospital or any individual responsible for any of the consequences and I may be personally responsible for my bill.

  7. PERSONAL VALUABLES: It is understood and agreed that money, jewelry, valuables, and other personal property should be locked up in the Hospital safe. Plains Memorial Hospital is not liable for the loss or damage to any money, jewelry, eyeglasses, dentures, documents, or other valuables, unless placed with the cashier for safekeeping.

  8. RELEASE INFORMATION: Consent is given to Plains Memorial Hospital, my family physician/health care provider, and testing and consulting physician(s)/health care providers, to release information from my medical record for the purpose of treatment, payment, or the Hospital's healthcare operations, as described in Plains Memorial Hospital's Notice of Privacy Practices. These purposes may include utilization review, determination of hospital or medical benefit coverage or eligibility or for computing hospitalization or medical benefits. Information may be released to the insurance carrier, agency or third party payor, including workers compensation, Medicare, utilization review organization or agency providing such benefits or reviewing or processing claims therefore. I understand that medical information may be released to any physician, hospital, nursing home, nursing service, or any other health care provider as may be requested in connection with the provision of additional medical care.

  9. PHOTOGRAPHS, VIDEOS: I understand that photographs, videotapes, digital, or other images may be recorded to document my care, and I consent to this. I understand that Plains Memorial Hospital will retain the ownership rights to these photographs, videotapes, digital images or other images, but that I will be allowed access to view them or obtain copies. I understand that these images will be stored in a secure manner that will protect my privacy and that they will be kept for the time period required by law or outlined in policy.

  10. LARGER COPY: A larger copy of this form is available upon request.