Common use of Personal Valuables Clause in Contracts

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. You acknowledge that XXX Xxxxx Health maintains a safe for securing money and/or other valuables. KRH Xxxxx Health 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 Xxxxx Health for storage in KRHXxxxx Health’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" • PATIENT BILL OF RIGHTS & RESPONSIBILITIES or “IMPORTANT MESSAGE FROM TRICARE FOR TRICARE BENEFICIARIES" • Xxxxx Health JOINT NOTICE OF PRIVACY PRACTICES (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 # #344 8/21 VERSION H

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 # #344 6/19 VERSION E ORIGINAL TO MEDICAL RECORDS OR SCANNED TO ACCOUNT • COPY TO PATIENT IN CASE OF ERRORS OR INQUIRIES ABOUT YOUR BILL The Federal Truth in Lending Act requires prompt correction of billing mistakes.

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 (“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 • LIST OF KRH ORGANIZATIONS AND SERVICES • 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 # #344 8/18 VERSION C

Personal Valuables. You acknowledge that XXX Xxxxx Health maintains a safe for securing money and/or other valuables. KRH Xxxxx Health 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 Xxxxx Health for storage in KRHXxxxx Health’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" • PATIENT BILL OF RIGHTS & RESPONSIBILITIES or “IMPORTANT MESSAGE FROM TRICARE FOR TRICARE BENEFICIARIES" • Xxxxx Health JOINT NOTICE OF OF PRIVACY PRACTICES (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 # #344 5/21 VERSION G

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 Your money, valuables, articles of unusual value, or any other personal property (“Property”), if Your Property is 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 • LIST OF KRH ORGANIZATIONS AND SERVICES • 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 DIRECTIVES – You have been advised of your Your right to formulate and execute an Advance Directive Directives and have has 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 # #344 1/17 ORIGINAL TO MEDICAL RECORDS OR SCANNED TO ACCOUNT • COPY TO PATIENT IN CASE OF ERRORS OR INQUIRIES ABOUT YOUR BILL The Federal Truth in Lending Act requires prompt correction of billing mistakes.

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" • PATIENT BILL OF RIGHTS & RESPONSIBILITIES or “IMPORTANT MESSAGE FROM TRICARE FOR TRICARE BENEFICIARIES" • KRH JOINT NOTICE OF OF PRIVACY PRACTICES (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. 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 (“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 • LIST OF KRH ORGANIZATIONS AND SERVICES • 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 Guardian or Legal Representative if not patient (please print) Relationship to the Patient: Patient Patient Name Witness Acct # MRN # #344 1/19 VERSION D