Common use of FACILITY DIRECTORY Clause in Contracts

FACILITY DIRECTORY.  If box is checked, I DO NOT want to be listed in the Facility directory. I unde rstand the Facility will not direct visitors/callers to me when they ask for me by name. I understand clergy will not be given my information to visit me unless specifically consulted, and special deliveries will be sent back to the vendor. IF INITIALED HERE (INITIALS), THIS AGREEMENT WILL REMAIN IN EFFECT AND APPLY TO ANY AND ALL OF MY ADMISSIONS AT ANY AND ALL FACILITIES UNTIL REVOKED BY ME IN WRITING TO: BAYCARE CENTRAL BUSINESS OFFICE, ATTENTION: MANAGEMENT SUPPORT, 0000 XXXXX XXXX, XXXXXXX, XX 00000. I UNDERSTAND THAT I MAY OCCASIONALLY BE ASKED TO UPDATE THE INFORMATION PROVIDED IN CONNECTION WITH THIS AGREEMENT OR TO SIGN A NEW AGREEMENT. I HEREBY AGREE THAT THE TERMS OF THIS AGREEMENT HAVE BEEN COMPLETELY READ, FULLY UNDERSTOOD, AND THAT I MAY OBTAIN A COPY OF THIS AGREEMENT UPON REQUEST. I CERTIFY THAT I AM THE PATIENT, OR THAT I AM DULY AUTHORIZED TO ACT AS THE PATIENT’S AGENT OR REPRESENTATIVE, AND I HEREBY VOLUNTARITY ACCEPT ALL THE TERMS AND CONDITIONS OF THIS AGREEMENT. Patient Signature Date Patient’s Date of Birth Patient unable to sign because: Signature of Patient’s Authorized Representative Relationship to Patient

FACILITY DIRECTORY.  □ If box is checked, I DO NOT want to be listed in the Facility directory. I unde rstand the Facility will not direct visitors/callers to me when they ask for me by name. I understand clergy will not be given my information to visit me unless specifically consulted, and special deliveries will be sent back to the vendor. IF INITIALED HERE (INITIALS), THIS AGREEMENT WILL REMAIN IN EFFECT AND APPLY TO ANY AND ALL OF MY ADMISSIONS AT ANY AND ALL FACILITIES UNTIL REVOKED BY ME IN WRITING TO: BAYCARE CENTRAL BUSINESS OFFICE, ATTENTION: MANAGEMENT SUPPORT, 0000 XXXXX XXXX, XXXXXXX, XX 00000. I UNDERSTAND THAT I MAY OCCASIONALLY BE ASKED TO UPDATE THE INFORMATION PROVIDED IN CONNECTION WITH THIS AGREEMENT OR TO SIGN A NEW AGREEMENT. I HEREBY AGREE THAT THE TERMS OF THIS AGREEMENT HAVE BEEN COMPLETELY READ, FULLY UNDERSTOOD, AND THAT I MAY OBTAIN A COPY OF THIS AGREEMENT UPON REQUEST. I CERTIFY THAT I AM THE PATIENT, OR THAT I AM DULY AUTHORIZED TO ACT AS THE PATIENT’S AGENT OR REPRESENTATIVEREPRESENTATIVE AND THE PATIENT HAS EXPRESSLY AUTHORIZED ME TO SIGN AND CONSENT ON HIS/HER BEHALF, AND I HEREBY VOLUNTARITY VOLUNTARILY ACCEPT ALL THE TERMS AND CONDITIONS OF THIS AGREEMENT. THIS DOCUMENT STANDS AS IS AND WITHOUT REVISIONS. Patient Signature Date Patient’s Date of Birth Patient unable to sign because: Signature of Patient’s Authorized Representative Relationship to Patient

FACILITY DIRECTORY.  □ If box is checked, I DO NOT want to be listed in the Facility directory. I unde rstand the Facility will not direct visitors/callers to me when they ask for me by name. I understand clergy will not be given my information to visit me unless specifically consulted, and special deliveries will be sent back to the vendor. IF INITIALED HERE (INITIALS), THIS AGREEMENT WILL REMAIN IN EFFECT AND APPLY TO ANY AND ALL OF MY ADMISSIONS AT ANY AND ALL FACILITIES UNTIL REVOKED BY ME IN WRITING TO: BAYCARE CENTRAL BUSINESS OFFICE, ATTENTION: MANAGEMENT SUPPORT, 0000 XXXXX XXXX, XXXXXXX, XX 00000. I UNDERSTAND THAT I MAY OCCASIONALLY BE ASKED TO UPDATE THE INFORMATION PROVIDED IN CONNECTION WITH THIS AGREEMENT OR TO SIGN A NEW AGREEMENT. I HEREBY AGREE THAT THE TERMS OF THIS AGREEMENT HAVE BEEN COMPLETELY READ, FULLY UNDERSTOOD, AND THAT I MAY OBTAIN A COPY OF THIS AGREEMENT UPON REQUEST. I CERTIFY THAT I AM THE PATIENT, OR THAT I AM DULY AUTHORIZED TO ACT AS THE PATIENT’S AGENT OR REPRESENTATIVE, AND I HEREBY VOLUNTARITY ACCEPT ALL THE TERMS AND CONDITIONS OF THIS AGREEMENT. Patient Signature Date Patient’s Date of Birth Patient unable to sign because: Signature of Patient’s Authorized Representative Relationship to Patient