LOGO DE PHGI

ACKNOWLEDGMENT OF INFORMATION RECEIPT FORM AND GENERAL CONSENT FOR PROVIDING HEALTH SERVICES

I.

Rights as a Patient: By signing this document I acknowledge that during the admission process to receive health services in Professional Hospital Guaynabo, Inc. (hereinafter the Hospital), I was provided with information concerning my rights as a patient, including but not limited to: (i) receive health care services consistent with the generally accepted principles of medical practice, (ii) to be treated with dignity and respect, (iii) to fully participate in all decisions regarding my health care, and (iv) to formulate advanced directives for my medical care and/or designate a person to decide on my behalf if I could not do it. Information about Benefits and Risks: I affirm that my physician(s) have provided me with an adequate explanation as to the procedure(s) and possible risks, benefits and alternatives to diagnostic and/or therapeutic procedures which I will be submitted in the Hospital. I also had opportunity to clarify all my doubts about the information I was provided. I acknowledge that my physician(s) have explained to me that any diagnostic or therapeutic procedure, which I may be submitted to in this Hospital, entails different kinds of risks from expected and unexpected causes. The risks include: incorrect results, infection, complications, severe blood loss, physical and/or emotional injuries, including the possibility of death. I was also warned that the medicine is not an exact science, therefore they cannot offer me any guarantee on the results and consequences of the diagnostic and/or therapeutic procedures which I will be submitted in the Hospital. Relationship Between the Hospital and my Physician(s): I am aware of the fact that if my physician(s) treat me in the Hospital does not mean that he (they) is (are) employee(s) nor agent(s) of the Hospital, nor that the Hospital control or manages the care that my physician(s) gives (gave) me. Other Physicians: I am aware that it is possible that during the diagnose and/or therapeutic process(es) that I received in the Hospital, there could be other physicians involved, such as anesthesiologists, pathologists and/or radiologists who usually provide support in such cases. I agree that these physicians provide me with the necessary medical services for my health care. I am also aware, that the fact that if these physicians provide me medical services in the hospital does not mean that they are employees, nor agents, or that the Hospital controls or manages the medical care they may gave me. Educational Activities: I acknowledge that the Hospital serves as a practical clinic for medical students and other health professions. Thus, it is possible that they participate and/or interfere in my health care. I consent that medical students and other health professions participate in my care, if it is under the direct supervision of a physician or licensed healthcare practitioner.

II.

III.

IV.

V.

INITIALS: ______

Page 1 de 3

VI.

Disclosure of Protected Health Information: I affirm to have been notified of my right that the information concerning my health is protected from inappropriate disclosures, and from the event that the Hospital may disclose health information related to me without my authorization.

VII. Removed Tissues or Organs: I recognize that when I submit to a surgical intervention, it is possible that some tissue, organ or limb of my body could be removed. I agree that the pathologist use and/or disposes of such tissue, organ or limb, as his or her best professional judgment. VIII. Pictures and Image Recording: By signing this document I do so knowing that it is possible that photographs and/or videos of the diagnosis or therapeutic processes that I may be submitted may be taken for medical, scientific or educational purposes. I authorize such photographs and/or videos to be taken, as long as they do not reveal my identity. IX. Personal Items: I am notified that I should not bring valuable objects to the Hospital that are not necessary for my health care and that if I bring them, the Hospital shall not be liable for the loss, destruction or robbery of my personal items. Grievances and Complaints: I acknowledge that I have received information on the availability of an internal Hospital procedure to promptly address and resolve complaints or grievances that I may have regarding medical and hospital services, as well as my right to present them directly to the federal or local government agencies. I am committed to conduct my complaints and grievances under the available procedure. Authorization: Through this document, I reaffirm my authorization for all health professionals working at the Hospital, including (the) physician (s) to whom (s) I have entrusted my health care, to provide me the diagnostic, care and therapeutic services, as an inpatient or outpatient, including the diagnostic and/or therapeutic services offered in the Emergency Room. These services may include, among others, radiological test, clinical or pathological laboratories, such as sexually transmissible disease tests, including human immunodeficiency virus (HIV) test, and surgical procedures.

X.

XI.

XII. Final Recognition and Reaffirmation of Consent: My signature in this form represents the following: A. Everything expressed before is correct and true; B. I read or was read to and understood the information provided in this form; C. I reaffirm everything I have recognized and accepted in this form and I do it voluntarily; D. I recognize that in the event in which any clause or part of this form is declared illegal or null by a Court, said declaration will not lessen the other clauses and its effect will be limited to the declared illegal or null clause.

INITIALS: ______

Page 2 de 3

AND TO CONFIRM, I SIGN THIS FORM. I sign this document on my behalf. In the event that the patient who receives the treatment is a minor or incapable to consent, my signature represents that I am the person entrusted and I have legal capacity to authorize and consent to what is expressed in this document in the name of the patient. Patients Name: ________________________________________ Patients Signature:_____________________________________________

Date: ___/___/____
(month/day/year)

Time: _______ AM/PM

If the patient cannot sign due to age minority or is physically or mentally impairment, please fill out the following information. Patients reason for not signing: [ ] Minority [ ] Impairment to consent [ ] Temporary [ ] Permanent Representative(s) Name(s): ______________________________________________ Representative(s) ID #:___________________________ Representative(s) relation with the patient: [ ] Father [ ] Mother [ ] Son or Daughter [ ] Spouse [ ] Other: Explain: __________________________

Representative(s) Signature(s): _________________________ Signature: __________________________________________ Signature: __________________________________________ Clerks Name: _______________________________________________ Signature:__________________________________________ Date: ___/___/____
(month/day/year)

Time: ________ AM/PM Date: ___/___/____

(month/day/year)

Time: ________ AM/PM

IMPORTANT NOTE: In the case of impairment due to minority, the consent of both parents (father and mother) is required, except in the case of emergency certified by the physician. Every person that signs in representation of a patient must provide valid identification to be photocopied and attached to the consent form.
Rev. 05/2009

INITIALS: ______

Page 3 de 3