Personal Valuables. You acknowledge that XXX maintains a safe for securing money and/or other valuables. KRH shall not be liable for the loss of or damage to your money, valuables, articles of unusual value, or any other personal property if not deposited with KRH for storage in KRH’s safe. BY SIGNING BELOW, YOU CONFIRM THAT YOU: (1) UNDERSTAND AND AGREE TO THE TERMS OF THIS AGREEMENT, (2) HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT THIS AGREEMENT AND (3) HAVE RECEIVED AND REVIEWED AND, IF NEEDED, COMPLETED THE FOLLOWING: • FEDERAL TRUTH IN LENDING ACT NOTIFICATION • PATIENT BILL OF RIGHTS & RESPONSIBILITIES • KRH JOINT NOTICE OF PRIVACY PRACTICES • AN “IMPORTANT MESSAGE FROM MEDICARE FOR MEDICARE BENEFICIARIES" or “IMPORTANT MESSAGE FROM TRICARE FOR TRICARE BENEFICIARIES" (Medicare and Tricare Inpatients, only) • ADVANCE DIRECTIVE – You have been advised of your right to formulate and execute an Advance Directive and have been provided with written information regarding the same. Patient Signature/Authorized Representative/Guarantor Date If an Authorized Representative/Guarantor, the nature of the relationship to the Patient: Patient Name Witness Acct # MRN #
Personal Valuables. I agree that BCDI is not liable for loss, theft, damage or destruction of any personal property on the premises including money, electronics, jewelry, glasses, dentures, hearing aids, and documents.
Personal Valuables. Sentara shall not be liable for loss of, or damage to, property not deposited with it for safekeeping. ( initials date) Communication Assistance: I and/or my companion(s) have been offered Communication Assistance on this date. Accepted ( initials date) ● Declined ( initials date) Notice of Privacy Practices: I have been offered a copy of Xxxxxxx’s Notice of Privacy Practices on this date. Accepted ( initials date) ● Declined ( initials date) Your Patient Rights and Responsibilities/Notice of Nondiscrimination: I have been offered a copy of Sentara’s Your Patient Rights and Responsibilities/Notice of Nondiscrimination on this date. Accepted ( initials date) ● Declined ( initials date) EACH UNDERSIGNED REPRESENTS THAT HE/SHE HAS READ AND FULLY UNDERSTAND THE MEANING AND EFFECTS OF THIS ENTIRE AGREEMENT, AND THAT SENTARA HAS MADE NO REPRESENTATION NOT HEREIN SET FORTH. CARBON COPIES AND PHOTOCOPIES HEREOF ARE DUPLICATE ORIGINALS FOR ALL PURPOSES. Date/Time Patient Signature Other responsible party signature Relationship o No Responsible Person Available (If checked, two witness signatures required.) o Patient unable to sign but has acknowledged an understanding of the above and consents to the undersigned witness printing his/her name. o Verbal consent to treat obtained from responsible party . Employee Witness Signature Date / Time Employee Witness Signature Date / Time
Personal Valuables. I understand that as a patient, I am encouraged to leave valuable personal items at home. While Mercy may maintain a safe for small personal items of usual value, Mercy is not responsible for the loss or damage to these items.
Personal Valuables. Currency, watches, rings, necklaces, wallets, credit cards and other personal valuables should be retained outside the Affiliate’s facility. Upon admission as an inpatient, if no one can retain such items outside the hospital, the patient may request to store items in the Affiliate’s safe. A special waiver form must be signed by the patient before the Affiliate accepts such valuables and before the patient is admitted to the unit. I understand that the patient will be responsible for all articles kept in the patient’s room, that the Affiliate assumes no control over personal valuables not deposited in its safe. I understand and agree that the Affiliate assumes no responsibility to reimburse for any loss or damage to money, jewelry, glasses, dentures, personal clothing or other articles brought by or for me to the Affiliate. I understand that the Affiliate maintains a safe for the storage of valuables and other articles during inpatient hospitalization that I may utilize upon request.
Personal Valuables. I understand and agree that the Hospital maintains a safe for the safekeeping of money and valuables. I agree that if I choose not to place valuables in the Hospital safe, the Hospital will not be responsible for the loss of, or damage to my valuables. The Hospital shall not be responsible for loss or damage to items including documents, cash, dental work or dental prosthetics, eyeglasses, credit cards, hearing aids, and items of unusual value or size that have not or cannot be placed in the Hospital safe. I have been advised that any personal valuables should be given to a family member or friend for safekeeping. With the exception of items placed in the Hospital safe and for which a receipt has been issued, I agree not to make any claims agains t and release Day Xxxxxxx Hospital and its staff from any and all liability for any loss or damage that may occur to my personal valuables.
Personal Valuables. It is agreed and understood that the surgery center shall not be responsible for any personal property brought by patient to the surgery center, including but not limited to money, jewelry, documents or any other articles.
Personal Valuables. The Hospital maintains a safe for the safekeeping of any money or valuables. I understand that the Hospital does not assume responsibility for the loss, damage, or disposal of my personal property or money including jewelry, clothing, dentures, eyeglasses, contact lenses, hearing aids, prosthetic devices, or any other item unless such money or property is deposited with the Hospital. I take full responsibility for any money or property retained in my possession/room or brought to me while I am a patient at the Hospital.
Personal Valuables. Lone Tree Surgery Center is not responsible for the loss or damage to personal belongings it keeps for a patient or visitor, including, without limitation, money, clothing, jewelry, glasses, dentures, hearing aids, electronic devices, documents, personal medical devices, or other valuable items.
Personal Valuables. Any personal property brought with Patient and not needed for purposes of Patient’s stay at the Saint Xxxxxxxxx facility must be taken home. Saint Xxxxxxxxx will not be liable for loss of, or damage to, any personal property of Patient except during periods such personal property has been placed in a Saint Xxxxxxxxx safe depository.
