Patient Information Packet 1-30-13

7/29/2019 Patient Information Packet 1-30-13

1/18


2/18


3/18


4/18


5/18

PLACE LABEL HEREGUARANTEE OF PAYMENT/ASSIGNMENT OF BENEFITS/AUTHORIZATION TO PROCESS CLAIMSCenter For Cancer CareGUARANTEE OF PAYMENT/ASSIGNMENT OF BENEFITS:In consideration of the Hospital's advancing credit to me for my hospital care and services, I hereby irrevocablyassign and transfer to Gwinnett Hospital System and treating Physicians all benefits and payments now due andpayable or to become due and payable to me under any insurance policy or policies, under any replacement policiesthereof, under any self-insurance program, under any third-party actions against any other person or entity, or underany other benefit plan or program (hereafter referred to as Benefits) for this or any other period of hospitalization andrelated outpatient care.

I understand and acknowledge that this assignment does not relieve me of my financial responsibility for all hospitalcharges and treating Physician charges incurred by me or anyone on my behalf, and I hereby accept suchresponsibility, including but not limited to payment of those fees and charges not directly reimbursed to the Hospitaland treating Physicians by any Benefit plan or program. Furthermore, I agree to pay all costs of collection,reasonable attorneys fees and court costs incurred in enforcing this payment obligation.

AUTHORIZATION TO PROCESS CLAIMS & RELEASE OF INFORMATION:I authorize Gwinnett Hospital System and the independent contractor physicians and/or professional corporations thatrender services to me to process claims for payment by my insurance carrier on my behalf for covered servicesprovided to me at Gwinnett Hospital System. I authorize the release of necessary information, including medicalinformation, regarding medical services rendered during this admission or any related services or claim, to myinsurance carrier(s), including any managed care plan or other payor, past and/or present employer(s), Medicare,CHAMPUS/TRICARE, authorized private review entities and/or utilization review entities acting on behalf of suchinsurance carrier(s), payers, managed care plans and/or employer(s), the billing agents and collection agents orattorneys of Gwinnett Hospital System and/or the independent contractor physicians and/or professionalcorporations, my employer's Worker's Compensation carrier, and, as applicable, the Social Security Administration,the Health Care Financing Administration, the Peer Review Organization acting on behalf of the federal government,and/or any other federal or state agency for the purposes(s) of satisfying charges billed and/or facilitating utilizationreview and/or otherwise complying with the obligations of state or federal law. Authorization is hereby granted torelease health record data and/or copies to my attending and/or admitting healthcare professional and/or any

consulting healthcare professional and/or any healthcare professional I may be referred to for follow-up care. I furtherauthorize Gwinnett Hospital System and any other healthcare provider or professional rendering services to me toobtain from any source medical history, examinations, diagnoses, treatments and other health or insuranceauthorization information for the purpose(s) of satisfying charges billed and/or facilitating utilization review, providingmedical treatment and/or the evaluation of such treatment, and/or otherwise complying with the obligations of state orfederal law. A photocopy of this Authorization may be honored.

MEDICARE PATIENT'S CERTIFICATION, AUTHORIZATION TO RELEASE INFORMATION, AND PAYMENTREQUEST:I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct.I authorize any holder of medical or other information about me to release to the Social Security Administration or itsintermediaries or carriers any information needed for this or a RELATED Medicare claim. I request that payment ofauthorized benefits be made on my behalf.

I understand my signature covers visits to the CENTER FOR CANCER CARE for 365 days from the date I s ignthis form.

SIGNED : ______________________________ ________________________ _________________ Patient/Patients Representative Relationship if other than self Date

WITNESS : ______________________________

Reason If Unable to Sign: __________________________________________________________________

*1-32651* FORM 1-32651 INITIATED 08/2012 Page 1 of1


6/18

GHS NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED

AND HO W YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

FORM 4-18967 REV. 07/2010 Page 1 of 3

For the purposes of this Notice of Privacy Practices (Notice), GwinnettHospital System, Inc. (The Hospital) and the physicians and other health care providers who are members of the Hospitals medical staff (the Medical Staff) work together in an organized health carearrangement to provide medical services to you when you are a patient inone of the Hospitals inpatient facilities (including Gwinnett MedicalCenter, Gwinnett Medical Center Duluth, Glancy Rehabilitation Center,Gwinnett Womens Pavilion, Gwinnett Extended Care Center) or outpatient diagnostic and treatment facilities or clinics. However,physicians and other health care providers who are members of theMedical Staff are engaged in the independent practice of medicine and arenot employees or agents of the Hospital. The Hospital and the MedicalStaff are referred to collectively in this Notice as GHS. As health careproviders, the GHS providers use confidential personal health informationabout patients, referred to below as protected health information (PHI).GHS protects the privacy of this information, and it is also protected fromdisclosure by state and federal law. In certain specific circumstances,pursuant to this Notice, patient authorization or applicable laws andregulations, PHI can be used by GHS or disclosed to other parties. Beloware categories describing these uses and disclosures, along with someexamples to help you better understand each category.

Uses and Disclosures for Treatment, Payment and Health CareOperations. GHS may use or disclose your PHI for the purposes of treatment, payment and health care operations, described in more detailbelow, without obtaining written authorization from you. In addition, theGHS providers may share your PHI as necessary to carry out itstreatment, payment and health care operations related to the organizedhealth care arrangement.

For Treatment. GHS may use and disclose PHI in the course of providing, coordinating, or managing your medical treatment,including the disclosure of PHI for treatment activities of another health care provider. These types of uses and disclosures may take

place between physicians, nurses, technicians, students, and other health care professionals who provide you health care services or areotherwise involved in your care. For example, if you are beingtreated by a primary care physician, that physician may need touse/disclose PHI to a specialist physician whom he or she consultsregarding your condition, or to a nurse who is assisting in your care.

For Payment. GHS may use and disclose PHI in order to bill andcollect payment for the health care services provided to you. For example, GHS may need to give PHI to your health plan in order to

be reimbursed for the services provided to you. GHS may alsodisclose PHI to its business associates, such as billing companies,claims processing companies, and others that assist in processinghealth claims. GHS may also disclose PHI to other health care

providers and health plans for the payment activities of such

providers or health plans.For Health Care Operations. GHS may use and disclose PHI as partof its operations, including for quality assessment and improvement,such as evaluating the treatment and services you receive and the

performance of its staff in caring for you, provider training,underwriting activities, compliance and risk management activities,

planning and development, and management and administration.GHS may disclose PHI to doctors, nurses, technicians, students,attorneys, consultants, accountants, and others for review andlearning purposes, to help make sure GHS is complying with allapplicable laws, and to help GHS continue to provide health care toits patients at a high level of quality. GHS may also disclose PHI toother health care providers and health plans for such entitys qualityassessment and improvement activities, credentialing and peer review activities, and health care fraud and abuse detection or

compliance, provided that such entity has, or has had in the past, arelationship with the patient who is the subject of the information.

Sharing of PHI Among the Hospital and the Medical Staff. As an

organized health care arrangement, the Hospital and the members of theMedical Staff will share with each other PHI that they collect from you asnecessary to carry out their treatment, payment and health care operationsrelating to the provision of care to patients by GHS.

Other Uses and Disclosures For Which Authorization is Not RequiredIn addition to using or disclosing PHI for treatment, payment and healthcare operations, GHS may use and disclose PHI without your writtenauthorization under the following circumstances:

As Required by Law and Law Enforcement. GHS may use or disclosePHI when required to do so by applicable law. GHS also may disclosePHI when ordered to do so in a judicial or administrative proceeding, toidentify or locate a suspect, fugitive, material witness, or missing person,when dealing with gunshot and other wounds, about criminal conduct, to

report a crime, the location of the crime or victims, or the identity,description, or location of a person who committed a crime, to report adeath or injury resulting from a boating accident, or for other lawenforcement purposes.

For Public Health Activities and Public Health Risks. GHS maydisclose PHI to government officials in charge of collecting informationabout births and deaths, preventing and controlling disease, reports of child abuse or neglect and of other victims of abuse, neglect, or domesticviolence, reactions to medications or product defects or problems, or tonotify a person who may have been exposed to a communicable diseaseor may be at risk of contracting or spreading a disease or condition.

For Health Oversight Activities. GHS may disclose PHI to thegovernment for oversight activities authorized by law, such as audits,investigations, inspections, licensure or disciplinary actions, and other

proceedings, actions or activities necessary for monitoring the healthcare system, government programs, and compliance with civil rightslaws.

Coroners, Medical Examiners, and Funeral Directors. GHS maydisclose PHI to coroners, medical examiners, and funeral directors for the purpose of identifying a decedent, determining a cause of death, or otherwise as necessary to enable these parties to carry out their dutiesconsistent with applicable law.

Organ, Eye, and Tissue Donation. GHS may release PHI to organ procurement organizations to facilitate organ, eye, and tissue donationand transplantation.

Research. Under certain circumstances, GHS may use and disclose PHIfor medical research purposes.

To Avoid a Serious Threat to Health or Safety. GHS may use anddisclose PHI, to law enforcement personnel or other appropriate persons,to prevent or lessen a serious threat to the health or safety of a person or the public.

Specialized Government Functions. GHS may use and disclose PHI of military personnel and veterans under certain circumstances. GHS mayalso disclose PHI to authorized federal officials for intelligence,counterintelligence, and other national security activities, and for the

provision of protective services to the President or other authorized persons or foreign heads of state or to conduct special invest igations.

Workers Compensation. GHS may disclose PHI to comply withworkers compensation or other similar laws. These programs provide

benefits for work-related injuries or illnesses.


7/18FORM 4-18967 REV. 07/2010 Page 2 of 3

Fundraising Activities. Your PHI may be used to contact you in aneffort to raise money for the Hospital. Your PHI may be disclosedto a foundation related to the Hospital. Such disclosure would belimited to contact information, such as your name, address and

phone number and the dates you required treatment or services atthe Hospital. The money raised in connection with these activitieswould be used to expand and support the Hospitals provision of health care and related services to the community. If you do notwant to be contacted as part of these fundraising activities, pleasenotify the Gwinnett Hospital System Foundation in writing.

Appointment Reminders; Health-related Benefits and Services;Marketing. GHS may use and disclose your PHI to contact you andremind you of an appointment at GHS, or to inform you of treatment alternatives or other health-related benefits and servicesthat may be of interest to you, such as disease management

programs. GHS may use and disclose your PHI to encourage youto purchase or use a product or service through a face-to-facecommunication or by giving you a promotional gift of nominalvalue.

Disclosures to You or for HIPAA Compliance Investigations. GHSmay disclose your PHI to you or to your personal representative,and is required to do so in certain circumstances described below inconnection with your rights of access to your PHI and to anaccounting of certain disclosures of your PHI. GHS must disclose

your PHI to the Secretary of the United States Department of Health and Human Services (the Secretary) when requested bythe Secretary in order to investigate GHS compliance with privacyregulations issued under the federal Health Insurance Portabilityand Accountability Act of 1996 (HIPAA).

Uses and Disclosures To Which You Have an Opportunity to Object . You will have the opportunity to object to these categories of uses anddisclosures of PHI that GHS may make:

Patient Directories. Unless you object, GHS may use some of your PHI to maintain a directory of individuals in its facility. Thisinformation may include your name, your location in the facility,your general condition ( e.g. fair, stable, etc.), and your religiousaffiliation, and the information may be disclosed to members of theclergy. Except for your religious affiliation, the information may be

disclosed to other persons who ask for you by name.

Disclosures to Individuals Involved in Your Health Care or Paymentfor Your Health Care. Unless you object, GHS may disclose your PHI to a family member, other relative, friend, or other person youidentify as involved in your health care or payment for your healthcare. GHS may also notify those people about your location or condition.

Other Uses and Disclosures of PHI For Which Authorization isRequired . Other types of uses and disclosures of your PHI not describedabove will be made only with your written authorization, which withsome limitations you have the right to revoke in writing.

Regulatory Requirements . GHS is required by law to maintain theprivacy of your PHI, to provide individuals with notice of it s legal duties

and privacy practices with respect to PHI, and to abide by the termsdescribed in this Notice. GHS reserves the right to change the terms of this Notice and of its privacy policies, and to make the new termsapplicable to all of the PHI it maintains. Before GHS makes an importantchange to its privacy policies, it will promptly revise this Notice and posta new Notice in all patient entry locations. You have the following rightsregarding your PHI:

You may request that GHS restrict the use and disclosure of your PHI. GHS is not required to agree to any restrictions you request,

but if GHS does so it will be bound by the restrictions to which itagrees except in emergency situations. Effective February 17, 2010,GHS is required by the Health Information Technology for Economic and Clinical Health Act (the HITECH Act) to honor anindividuals request to restrict disclosures of PHI to health plans for

payment or health care operations purposes if the PHI pertains solely toitems and services paid for by the individual in full.

You have the right to request that communications of PHI to you fromGHS be made by particular means or at particular locations. For instance,you might request that communications be made at your work address, or

by e-mail rather than regular mail. Your requests must be made inwriting and sent to the Privacy Officer. GHS will accommodate your reasonable requests without requiring you to provide a reason for your request.

Generally, you have the right to inspect and copy your PHI that GHSmaintains, provided that you make your request in writing to theHospitals Department of Health Information Management. Within thirty(30) days of receiving your request (unless extended by an additionalthirty (30) days), GHS will inform you of the extent to which your requesthas or has not been granted. In some cases, GHS may provide you asummary of the PHI you request if you agree in advance to such asummary and any associated fees. If you request paper copies of your PHI or agree to a summary of your PHI, GHS may impose a reasonablefee to cover copying, postage, and related costs. To the extent capable,GHS will comply with your request for a copy of your PHI in anelectronic format. If GHS denies access to your PHI, it will explain the

basis for denial and your opportunity to have your request and the denialreviewed by a licensed health care professional (who was not involved inthe initial denial decision) designated as a reviewing official. If GHS

does not maintain the PHI you request, if it knows where that PHI islocated it will tell you how to redirect your request.

If you believe that your PHI maintained by GHS contains an error or needs to be updated, you have the right to request that GHS correct or supplement your PHI. Your request must be made in writing to theHospitals Department of Health Information Management, and it mustexplain why you are requesting an amendment to your PHI. Within sixty(60) days of receiving your request (unless extended by an additionalthirty (30) days), GHS will inform you of the extent to which your requesthas or has not been granted. GHS generally can deny your request if your request relates to PHI: (i) not created by GHS; (ii) that is not part of therecords GHS maintains; (iii) that is not subject to being inspected by you;or (iv) that is accurate and complete. If your request is denied, GHS will

provide you a written denial that explains the reason for the denial andyour rights to: (i) file a statement disagreeing with the denial; (ii) if youdo not file a statement of disagreement, submit a request that any futuredisclosures of the relevant PHI be made with a copy of your request andGHSs denial attached; and (iii) complain about the denial. You generallyhave the right to request and receive a list of the disclosures of your PHIthat GHS has made at any time during the six (6) years prior to the date of your request (provided that such a list would not include disclosures made

prior to April 14, 2003). The list will not include disclosure for whichyou have provided a written authorization, and does not include certainuses and disclosures to which this Notice already applies, such as those:(i) for treatment, payment, and health care operations; (ii) made to you;(iii) for the Hospitals patient directory or to persons involved in your health care; (iv) for national security or intelligence purposes; or (v) tocorrectional institutions or law enforcement officials. You should submitany such request to the Hospitals Department of Health Information

Management, and within sixty (60) days of receiving your request (unlessextended by an additional thirty (30) days), GHS will respond to youregarding the status of your request. GHS will provide the list to you atno charge, but if you make more than one request in a year you may becharged a fee for each additional request. You have the right to receive a

paper copy of this Notice upon request, even if you have agreed to receivethis Notice electronically. You can receive a copy of this Notice at our Web site, http://www.gwinnetthealth.org. To obtain a paper copy of this

Notice, please contact the GHS Privacy Officer.

You may complain to GHS if you believe your privacy rights with respectto your PHI have been violated by contacting a Hospital PatientRepresentative or the GHS Privacy Officer and submitting a writtencomplaint. GHS will in no manner penalize you or retaliate against youfor filing a complaint regarding GHS privacy practices. You also have


8/18FORM 4-18967 REV. 07/2010 Page 3 of 3

the right to file a complaint with the Secretary of the Department of Health and Human Services.

If you have any questions about this Notice, please contact the GHSPrivacy Officer by mail at 1000 Medical Center Boulevard,Lawrenceville, Georgia 30046, by telephone at (678) 312-3900 or byemail at [email protected].

If you have any questions about your medical records, please contact theMedical Records Department by mail at 1000 Medical Center Boulevard,attn Medical Records, Lawrenceville, GA 30046, or by telephone at

(678)-312-4490.Effective Date: April 14, 2003.


9/18

PATIENT E-MAIL CONSENTCenter for Cancer CarePatient name: ____________________________________ E-mail: __________________________________

Patient address: ___________________________________________________________________________

Provider: _________________________________________________________________________________ 1) RISK OF USING E-MAILTransmitting patient information by e-mail has a number of risks that patients should consider before using e-mail. Theseinclude, but are not limited to, the following:

A) E-mail can be circulated, forwarded, stored electronically and on paper, and broadcast to unintendedrecipients.B) E-mail senders can easily misaddress an e-mail.C) Backup copies of e-mail may exist even after the sender or the recipient has deleted his or her copy.D) Employers and on-line services have a right to inspect e-mail transmitted through their systems.E) E-mail can be intercepted, altered, forwarded, or used without authorization or detection.F) E-mail can be used to introduce viruses into computer systems.G) E-mail can be used as evidence in court.H) E-mails may not be secure, including at Center for Cancer Care, and therefore it is possible that theconfidentiality of such communications may be breached by a third party.

2) CONDITIONS FOR THE USE OF E-MAILProvider cannot guarantee but will use reasonable means to maintain security and confidentiality of e-mail informationsent and received. Providers are not liable for improper disclosure of confidential information that is not caused byProviders intentional misconduct. Patients must acknowledge and consent to the following conditions:

A) E-mail is not appropriate for urgent or emergency situations. Provider cannot guarantee that anyparticular E-mail will be read and responded to within any particular period of time.B) E-mail must be concise. The patient should schedule an appointment if the issue is too complex or sensitive todiscuss via e-mail.C) All e-mail will usually be printed and filed in the patients medical record.D) Office staff may receive and read your messages.E) Provider will not forward patient identifiable e-mails outside of Center for Cancer Care healthcare providers without

the patients prior written consent, except as authorized or required by law.F) The patient should not use e-mail for communication regarding sensitive medical information.G) Provider is not liable for breaches of confidentiality caused by the patient or any third party.H) It is the patients responsibility to follow up and/or schedule an appointment if warranted.

3) INSTRUCTIONSTo communicate by e-mail, the patient shall:

A) Avoid use of his/her employers computer.B) Put the patients name in the body of the e-mail.C) Key in the topic (E.G., medical question, billing question) in the same line.D) Inform provider of changes in his/her e-mail address.E) Acknowledge any e-mail received from the Provider.F) Take precautions to preserve the confidentiality of e-mail.

4) PATIENT ACKNOWLEDGEMENT AND AGREEMENTI acknowledge that I have read and fully understand this consent form. I understand the risks associated with thecommunication of e-mail between the Providers and me, and consent to the conditions and instructions outlined, as wellas any other instructions that the Provider may impose to communicate with patient by e-mail. If I have any questions Imay inquire with my treating physician.

_____________ _______________________________________________________ Date Patient signature

_____________ _____________ ____________________________________________________ Date Time Witness signature

*1-32766* FORM 1-32766 INITIATED 09/2012 Page 1 of 1


10/18

PATIENT HISTORYCenter for Cancer CareNAME: ________________________________________ DATE: __________________________

PATIENT PROFILEPlace of birth: ________________________________ Highest Grade Completed: _________________ Occupation: _________________________________ Religion: _______________________________ Tobacco use: ________________________________ Alcohol use: ____________________________

PAST MEDICAL HISTORY (Check if appropriate)Skin cancer Ulcer Heart attack ArthritisThyroid disease Hepatitis Other heart disease Head injuryDiabetes Intestinal disease Lung disease CancerPneumonia Gallbladder disease High blood pressure PhlebitisTuberculosis Kidney/bladder disease Stroke AsthmaBlood transfusion Venereal disease Seizures High cholesterol

LIST ALL MEDICATIONS

Drug Dose Frequency1. __________________________________________________________________________________ 2. __________________________________________________________________________________ 3. __________________________________________________________________________________ 4. __________________________________________________________________________________ 5. __________________________________________________________________________________

LIST ALL PROCEDURESProcedure Date Hospital

1. __________________________________________________________________________________ 2. __________________________________________________________________________________ 3. __________________________________________________________________________________

4. __________________________________________________________________________________ 5. __________________________________________________________________________________

ALLERGIES NONE DYE LATEX

DRUG: Please List Drug and Reaction:

Other: Please List with Reaction :

FAMILY HISTORY If Living If DeceasedAge Health Age at death Cause

Father: _____________________________________________________________________________ Mother: _____________________________________________________________________________

Brother/Sister: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________

Husband/Wife: _______________________________________________________________________ Children _______________________________________________________________________

_______________________________________________________________________ _______________________________________________________________________



11/18

PATIENT HISTORYCenter for Cancer Care

Have any blood relatives ever had? (Check if appropriate)Cancer Heart disease Other: ________________________ Bleeding disorder Diabetes _________________________ Anemia Kidney disease _________________________

Have you had any of these in the last three months?

NO YES NO YESGENERAL INTESTINAL

Change in weight Nausea / VomitingFever / Chills Vomiting bloodNight sweats Difficulty swallowing

SKIN Abdominal pain / swellingItching Yellow jaundiceRash Blood in stool / black stoolChange in mole Diarrhea / constipation

Change in bowel habits

GLANDS URINARYHeat / cold intolerance Burning / painful urinationX-ray treatments to neck Blood in urineExcessive thirst / urination Nighttime urination

Change in urine streamEENT Sores on genitals

Change in vision SKELETALDouble vision Joint pain / stiffnessDifficulty hearing Back painFrequent bloody nose NEUROLOGICALSinus infection Frequent / severe headacheHoarseness Numbness / tinglingRinging in ears Incoordination

Sores in mouth

Limb weaknessPsychiatric illnessHEART / LUNGS Unusual anxiety / depression

Chest pain Drug / Alcohol addictionCough FOR WOMENCoughing blood Bleeding between periodsShortness of breath Bleeding since menopauseWheezing Pain in female organs Irregular / racing heartbeat Breast lump / painBlack out spells Nipple dischargeAnkle swellingAching in legs when walking FOR MEN

Lump / pain in testicleBLOOD Impotence

Anemia DischargeUnusual dietary cravingExcessive bruising / bleedingEnlarged lymph nodes

FORM 2-32767 INITIATED 09/2012 Page 3 of 3


12/18


13/18

PLACE LABEL HERE

NOTICE PRIVACY PRACTICES andPERSONAL REPRESENTATIVE


ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES (NPP) :My signature below acknowledges that I have received or have been offered a copy of Gwinnett Health Systems (GHS)Notice of Privacy Practices, and I am aware that I have access to this document on the health systems website atwww.gwinnettmedicalcenter.org.

ORIn an emergency treatment situation, obtain the NPP acknowledgement as soon as it is reasonably practicable to do so after the emergency situation has ended.

___The Patient is unable to sign because (check one) Patient is Critical or Unconscious. Patient Refuses to Sign.

___CERTIFICATION OF GOOD FAITH EFFORTS TO OBTAIN ACKNOWLEDGEMENT OF NOTICE OF PRIVACYPRACTICES (NPP): I hereby certify that as an associate or agent of GHS, I have made a good faith effort to obtain fromthe patient or the patients authorized representative a written acknowledgment of the GHS NPP in accordance with itsProvision of Notice of Privacy Practices, (policy #100-105.)

__________________________________________________________________________ DESIGNATION OF PERSONAL REPRESENTATIVE:

As a patient, you may designate one or more personal representatives. A personal representative may receive ProtectedHealth Information (PHI) about you. PHI includes information about your current medical condition and diagnosis, treatmentand prognosis, and billing and payments. Personal representatives will not have access to PHI in the periods that arebetween treatments or admissions. My personal representative(s) is listed below and my signature of approval.

A personal representative may be a spouse, relative, domestic partner, or friend. You can remove or add personalrepresentatives at any time, including during treatment or upon another admission to a GHS facility.

_____ I (Patient) do not wish to designate a personal representative. I understand that the hospitals healthcare team(initial) may designate an interim personal representative, if designating a personal representative will expedite or enhance

my care as a patient.

I (Patient) designate the following as my personal representative(s) :

_________________________________________________________ (Name of Personal Representative)

________________________ (Relationship)

_________________________________________________________ (Address, if known)

________________________ (Telephone number)

_________________________________________________________ (Name of Personal Representative)

________________________ (Relationship)

_________________________________________________________ (Address, if known)

________________________ (Telephone number)

________________________________________________________ ________________________________________ Patient or Authorized Representative Signature Date

______________________________________ __________________________ ________________________________________ GHS Representative Name Department Position


14/18

INDIGENT CARE TRUST FUND NOTICE

Page 1 of 1

Do You Need Help to Pay Your Hospital Bill?

Gwinnett Medical Center participates in the Georgia Indigent Care Trust Fund. As our patient, you receive certain benefits under the Trust Fund.

You have a right to: The availability of free and reduced-charge services. The availability to gain admittance without pre-admission deposits. Not be transferred solely or insignificant part for economic reasons. The availability of services provided. The terms of eligibility for free and reduced services. The application process for free and reduced-charges. The person or office to whom complaints or questions about the hospitals

participation in or operation of the program may be directed.

Primary care services: We spend part of the money from the Trust Fund to improve primary care services inour community so that you will have better access to preventive services you need.The services we offer are: Miles and Lib Mason Childrens Clinic, Gwinnett PhysiciansGroup OB Gyn, and several outpatient testing centers.

Help with your hospital bills:You may be eligible for financial help with your bills for inpatient and outpatientservices at our hospital. Under the Trust Fund, we offer a certain amount of free andreduced-charge care each year. Financial assistance information can be obtained by:

Talking with our Benefits Counselor in the Center for Cancer Care Accessing our website: gwinnettmedicalcenter.org

If you have problems:

If you have any concerns about how we operate programs under the Trust Fund rules,please let us try to work with you to resolve them. However, if you are not satisfied withour handling of your situation, you may contact the Department of Community Health:

Mail: 2 Peachtree St., NW, Atlanta, GA 30303 Telephone: 404-656-4507 Web: dch.georgia.gov


15/18

tHe Center for Cancer Care

1

Integrated Cancer Center with Gwinnett Medical Center

Why are we doing this?

This relationship is a major step in creating a more comprehensive cancer program for our community. We want to make it as easy and convenient as possible for you to get the cancer care you need. Thanks to our relationship with Gwinnett Medical Center, we are now able to offer all patients infusion/injection services at our office locations. So, if you received infusion treatments at a hospital in the past, you can now receive these services in our office. This change will most likely save you some time, and youll be able to receive care from the people who you have come to know and trust.

Whats changing?

As mentioned above, thanks to the relationship between Suburban Hematology Oncology Associates and Gwinnett Medical Center, we can now offer infusion/injection services at our spacious, modern facilities in

Lawrenceville, Duluth

and

Snellville.

In

recognition

of

the

strong

ties

between

our

two

organizations,

the

nameof the infusion center at Suburban Hematology Oncology Associates will now become the Center for Cancer

Care, a service of Gwinnett Medical Center.

What isnt changing?

You will continue to see the same experienced physicians and staff that you have in the past and our

commitment to providing quality care in a comfortable, compassionate setting remains unchanged. We will continue to treat you not just as a patient, but as a person, and we will work with you to produce the best

possible outcomes.

Whats more, if you should require inpatient care, you will have convenient access to the excellent diagnostic and inpatient services at Gwinnett Medical Centers hospitals in Lawrenceville and Duluth.

We will also try to take some of the stress out of what can be a very challenging time in your life. Well help you to understand your treatment options and to get the care you need, regardless of your financial situation

including connecting you with outside resources to help you cover the costs of treatment.

How will the cost of my care be affected?

Just as your treatment is unique, so is your financial situation. Our benefits counselors can work with you to

determine your specific responsibilities and the resources, including your insurance provider, to help pay for the cost of your care.

Can I continue to have my lab work here?

Yes. We now have the ability to perform more testing within our facility.


16/18

tHe Center for Cancer Care

2

Can I continue to see my same doctor?

Yes. You will continue to see the same physician. There will not be any changes to your treatment path as a result of this partnership. Only you and your doctor will determine what care is appropriate.

Will my insurance co payment and co insurance amounts change?

The Center for Cancer Care now bills under Gwinnett Medical Centers tax identification number. The tax identification number is used by insurance companies to discover the specific contract with healthcare providers. Any plan the hospital is contracted with will be the same as the center. Every plan is different; the policy terms are used to determine insurance payment amounts, contractual amounts (the portion your doctor and center agree to accept), and patient responsibility amounts. So, you should anticipate a possible change in your copayments and coinsurance amounts. Our benefits counselors are here to help you

understand your

insurance

benefits

and

provide

payment

options.

How will I know what I owe?

Our benefits counselors will verify your benefits and determine what will be paid by your insurance company and provide an estimate of what amount, if any, you will owe. We will explain your benefit coverage details and any amount due once we discover youre individual plan.

In some cases we will not know before your visit exactly what treatment youll be receiving. If an amount due cannot be determined we will give you the basic policy information such as deductibles and max out of pocketportions as a starting point. We will file your insurance and bill you for any remaining balance.

Will the bill come from Gwinnett Medical Center?

The staff that has been filing your insurance claims will continue to prepare and submit your claims to your insurance company. If there is a remaining balance, we will mail you a statement. The name on the statementwill be The Center for Cancer Care, a service of Gwinnett Medical Center. We are available to discuss statements within the center on follow up visits by our associates. Those bills can only be discussed within theCenter. Main hospital associates will not have your statement information so its important to call the numbers listed on the statement if you have a question or speak to us in person.

I have Medicare, will I experience any changes?

You will have a new form to read and sign. It pertains to you acknowledging that you are being treated at a

hospital based center which may increase the coinsurance amount you owe. The form is a CMS requirement.

I am uninsured will there still be assistance and financial resources available to me?

Yes. Our benefit counselors will continue to help you find the right financial resources that fit your financial situation. Also, the hospital financial assistance program is available.


17/18

Q Gwinne Hosp tal S ys emMEDICARE OUTPATIENTCO- NSURANCE NOT CE

To Our Medicare Patients at the Center for Cancer Care - Sne vi e:

This facility s opera ed a an outpat ent depa tment aff ated wi h Gw nne Med cal Cente A anou pa en depa tment o the o pi a , i con idered o be a provide - ased depa tmen As aece ve of se vices a t s ac ty, you a e a pat en o Gwinne Medical Center (Gw nnet Hosp alSy em, Inc.).

Med care regulation equire u o p ov de you w h a no ce o your potential nanc a liab ty for eho pi a se vice s you wil rece ve Your co-insu ance a i y o hospital se vices is sepa ate f omhe Medica e co insu ance ability hat you may owe fo t e p ys cian se vice p ovided o you n

conjunc on wit t e e o pi al e v ces.

We a e equired o advi e you a because a depar men of the ospital u n s es t e serv ces, you w l ncur a co- nsurance liab ity o e hosp ta hat you would ot e w se not ncur f t e se v ces we e urn s ed in an entity hat is not hosp ta ba ed

W en you meet w th our Bene s Counse or you wi e p ovided a ul explanat on of t e e pectedco insurance amoun that you w l owe th oug ou you ca e e actua amount o you co insurance may be differen om e e mate ecau e actual co insu ance lia ty ub ec oservice eceived and f na determinat on by the Medica e prog am

you are enrol ed in t e s ate medica ass s ance p og am Geo g a Med caid, your co n u anceab ty may be educed or elim nated by law Be sure you ave p ovided us a copy o youMed ca d ca d

I g I w ll l b l y p l p m by l w.

S gnature o Pa en o Au horized Rep esen a ve Date


18/18

Determination of Primary & Secondary Insurance when Patient is Entitled to Medicare

Medicare will be primary when a patient with Medicare has no other insurance, has Medigap Supplementalinsurance, has Medicaid in addition to Medicare, and/or is in one of the following situations:

Please place a checkmark next to the ONE statement of the following that is true for you:

______ 1) I am 65 or over, fully retired, and my spouse is also fully retired. Medicare is primary. Date of retirement__________ Date of Spouses Retirement________

______ 2) I am 65 or over, fully retired, & my spouse works for a company with LESS than20 employees. Medicare is primary for me.

______ 3) I am 65 or over, and work full-time or part-time for a company with LESS than 20employees. Medicare is primary.

______ 4) I am under 65, am disabled, and I do not have primary coverage with a Large Grouphealth Plan because I do not have nor does a family member have current employmentstatus*. Medicare is primary.

______ 5) I am a Veteran entitled to Medicare, and I may choose either the VA or Medicare to beresponsible for payment of services covered by both programs.

______ A) If I choose Medicare, Medicare is primary for me. It is not necessary to submit aclaim to the VA for denial before sending to Medicare.

______ B) If I choose the VA, Medicare is secondary & all hospital services must be pre-authorized by the VA.

Medicare will be Secondary Payor for a Patient with Medicare when:

______ 1) I am 65 or over, fully retired, and my spouse works for a company with MORE than 20employees. Medicare is secondary for me.

______ 2) I am 65 or over, and work full time or part-time for a company with MORE than 20employees. Medicare is secondary for me.

______ 3) I am under 65, am disabled, & I have primary coverage through a LGHP. Medicare issecondary for me.

______ 4) I have End State Renal Disease. My Medicare coverage began _________.Medicare is secondary for me for the first 18-month or 30-month coordination period.

______ 5) I am entitled to Black Lung benefits. Medicare is secondary for me only for treatment of lung conditions caused by mining.

______ 6) I was injured in an accident. ___ Auto ___ Work ___ Home ___ Other

Detailed billing information will be requested separately. Medicare is second for me.

Current Employment Status means that an individual is actively working as an employee, is theemployer, or is associated with the employer in a business relationship.

By completing this questionnaire and signing below, I acknowledge that _____________has made a good faitheffort to determine whether any other insurance is primary to any Medicare coverage I may have.

_____________________________________ ________________ __________________________ Beneficiarys (PRINTED) Name Date Beneficiarys Signature

GHS - CCC

Patient Information Packet 1-30-13

Documents

Transcript of Patient Information Packet 1-30-13