Hospital Directory. Except for patients receiving mental health services, unless you object we will include certain limited information about you in the hospital directory while you are in the hospital. This information may include your name, location in the hospital, your general condition (e.g., fair, stable, etc.) and your religious affiliation. The directory information may also be released to individuals, such as your family, friends, a member of the clergy, who ask for you by your full name. This is so your family, friends and clergy can visit you in the hospital and generally know how you are doing. However, for patients receiving mental health services, we will not disclose that the patient is receiving care at the hospital, unless an official at the hospital determines that the release of such information to any of the following persons is in the patient’s best interest: (1) members of the patient’s family; (2) the patient’s lawyer; or (3) the patient’s guardian or conservator.
Hospital Directory. We will include your name and room number/telephone number in the Hospital's directory. This information may be provided to members of the clergy and to other people who ask for you by name. You have the right to opt out of including your information in the directory. It is important to understand that if you opt out, you will not receive any phone calls (even from family), visitors will be told that you are not here and any flowers or gifts will be sent back. If you want to opt out, you should request to speak to the charge nurse.
Hospital Directory. While staying at a Saint Xxxxxxxxx facility, Patient will be listed in a directory containing Patient’s name, location and general condition. Such information facilitates family and friends visiting Patient, but I may decline to have Patient listed. This form has been explained to me, and I certify that I have read it, understand its contents, and have had an opportunity to have my questions answered. By signing this form, I consent to medical care by Providers and to each of the provisions set forth in this form. In the event I do not understand, or consent to, any provision of this form, I will immediately speak with a representative of Saint Xxxxxxxxx to ask questions or to register my lack of consent. I acknowledge, however, that in certain cases such lack of consent may prevent Providers from providing Patient with medical services, may shift all or a portion of the financial obligation for such services to me, and/or may be of no effect to the extent Saint Xxxxxxxxx has already taken action in reliance upon any consent given hereby. Signature of Patient Date Time The patient is unable to sign because . For this reason, I give consent to the Procedure on behalf of the above-named patient. Signature of Patient’s Representative Relationship to Patient Date Time Language Line utilized, or Hospital interpreter Interpreter’s Name Signature and/or ID# Date Time
