Fill out the below information for the patient (individual who is being assessed/treated). If you have questions regarding this form, contact the Linden Oaks Business Office at 630-305-5096. 

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1. CONSENT TO TREAT: I, (the Patient signing below, or person signing below who is responsible for consenting on Patient's behalf) consent to medical treatment (inpatient, outpatient), diagnostic procedures, administration of medications, deemed necessary and appropriate to treat my condition or illness rendered to me at Linden Oaks Hospital. I understand that physicians, nurses, other health care providers in training, or representatives from medical and device manufacturing companies who provide technical support may, under the supervision of appropriate personnel, participate in my treatment and I consent to their involvement in my care.
2. ACKNOWLEDGMENT: I understand that the practice of medicine is not an exact science. I understand and agree that no guarantees have been made, or can be made, as to the result of diagnosis, treatments and medications, tests or examinations.
3. INDEPENDENT PHYSICIANS ARE NOT EMPLOYEES OR AGENTS OF LINDEN OAKS HOSPITAL: I understand that all of the physicians treating me at LINDEN OAKS Hospital except the Linden Oaks Medical Group physicians are independent physicians and are not agents or employees of Linden Oaks. By signing this form I acknowledge that these independent physicians are not employed, supervised, or controlled by Linden Oaks Hospital. I understand that each of these physicians has staff privileges but treats patients based upon his/her own independent medical judgment and that he/she, and not Linden Oaks Hospital, is solely responsible for the care, treatment, and services that he/she orders, requests, directs, or provides. I further acknowledge that the employment or agency status of the physicians who treat me is not relevant to my selection of Linden Oaks Hospital for my care. I also understand that I will receive, and am solely responsible for payment of, a separate bill from the LOMG and independent physicians for the care, treatment, or service they provide to me.
4. RESPONSIBILITY FOR PAYMENT: In consideration of the services provided by Linden Oaks Hospital, I agree to guarantee payment of all charges that are related to the services provided to the Patient. I agree to be fully responsible for the payment of any and all charges if these charges are not covered by insurance. I understand that it is my responsibility to check with my insurance carrier to determine whether the costs associated with the services provided to me at Linden Oaks Hospital are covered. Failure to pay may result in referral of said account to a commercial collection agency and/or credit bureau. Should the account be referred to any agency or attorney for collection, the undersigned shall pay reasonable attorney's fees and collection expenses. If I receive payment directly for the medical charges associated with my treatment, I acknowledge it is my responsibility to pay such payment to Linden Oaks Hospital. I acknowledge that I may receive additional separate charges including but not limited to laboratory, radiology and other ancillary services.
5. ASSIGNMENT OF BENEFITS/INSURANCE ELIGIBILITY: In consideration of those health care services rendered, I hereby assign to Linden Oaks Hospital and authorize  direct  payment  to Linden Oaks Hospital, any insurance, health plan or third party benefits  otherwise payable to  me  or on my behalf.
6. FINANCIAL ASSISTANCE: Linden Oaks Hospital provides many services to assist uninsured patients as well as patients who cannot afford the cost of care. I understand that if I have any questions about its financial assistance policy I may ask the Business Office or contact the patient accounts department at 630-527-3100.
7. FOR MEDICARE/MEDICAID PATIENTS: I certify that any information given by me as the Patient or Patient's Representative in applying for payment by Medicare or Medicaid is correct. I authorize any holder of medical or other information about Patient to release to Medicare or its agents any information needed for this or a related medical claim. I authorize payment of benefits to Linden Oaks Hospital on the Patient's behalf. If Patient is a hospital inpatient, I certify that I have been given a copy of "An Important Message from Medicare".
8. RELEASE OF INFORMATION FOR PAYMENT: I authorize Linden Oaks Hospital to release any and all relevant information about me from my records, including HIV, to any third party payers responsible for payment of charges, including insurance companies, health benefit plans, and governmental agencies. 1 acknowledge that I must request and complete an insurance restriction waiver form if I do not want any information regarding my visit shared with my insurance company and understand that I will then become personally responsible for payment.
9. PATIENT RIGHTS AND NOTICE OF PRIVACY PRACTICES: I acknowledge that I have been offered a copy of the Patient's Rights and Responsibilities and the Notice of Privacy Practices.
10. PERSONAL BELONGINGS: I understand that Linden Oaks Hospital is not responsible for any Patient clothing, valuables, or other personal belongings kept with the Patient during his/her visit. I hereby release the facility from any liability for any and all personal possessions kept with the Patient during his/her visit.
11. PROPERTY DAMAGE: I understand that I am responsible and accept liability for any damage to or destruction of Linden Oaks' property, or property belonging to others that is caused by the Patient.
12. No revisions or changes to this form by you will be accepted by Linden Oaks Hospital.

Telemedicine is the practice of medicine that involves the use of electronic communications to diagnose or treat patients located in Illinois who are in different locations from their healthcare providers. Telemedicine also enables healthcare providers at different locations in Illinois to share individual patient medical information for the purpose of improving patient care.

By executing this form, I, as patient or patient's legal representative, (MPatient") consent to the utilization of telemedicine technologies in the course of my medical treatment and authorize Edward-Elmhurst Health, its employed and/or contracted providers, including primary care practitioners, specialists, and/or subspecialists, its staff, and subcontractors (collectively, MProviders") to review and exchange medical information about Patient for the purpose of Patient's treatment via telemedicine.

I understand that Patient medical information may be used by Providers for diagnosis, therapy, follow-up and/or education, and may include, but not be limited to, any of the following:

• Evaluation of Patient and Patient medical records;
• Evaluation of Patient diagnostic and laboratory test results;
• Live two-way audio and video recordings of Patient and Providers; and
• Output data from medical devices and sound and video files of Patient communications.

Benefits of Telemedicine Services:

• Improved access to medical care by enabling a patient to remain in his/her location while the physician consults and obtains test results at distant/other sites;

Possible Risks of Telemedicine Services:

As with any medical procedure, there are potential risks associated with the use of telemedicine technologies in treating patients. While these risks will vary with the type of treatment obtained by Patient, they generally include, but may not be limited to:

• The Provider or on-site consultant may determine that the transmitted information is of inadequate quality, thus necessitating a face-to-face meeting with the Patient and Physician, or at least a rescheduled video consult between the Patient and Physician;
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment used in a telemedicine encounter;
• In rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
• In rare cases, a lack of access to complete medical records may result in treatment delays, adverse drug interactions, allergic reactions, or other judgment errors.

Informed Consent for Telemedlcine Services

By signing this form, I, as Patient, acknowledge and affirm that it has been explained to me and I understand the following:

1. Not all conditions are appropriate for diagnosis and/or treatment via telemedicine;
2. Telemedicine services, unlike direct in-person health care, are provided without direct, physical contact between a patient and healthcare provider and therefore present additional risks, including but not limited to, the risks listed above as well as failure to identify relevant symptoms, failure to diagnose or timely diagnose a condition, time delays between diagnosis and obtaining appropriate treatment requiring physical contact with a provider, and disruptions in care due to technological failures;
3. Patient is aware that alternatives to a telemedicine consultation are available and Patient will have an opportunity to discuss them and concerns with Provider when initiating telemedicine services;
4. The types of activities that are permitted using telemedicine services are limited by state law, insurance, payor source, and the practicalities of a patient's condition, but generally include patient evaluation, diagnosis, treatment, prescribing medications (other than controlled substances and, for other legend drugs, only in the limited circumstances permitted by applicable federal and state law), obtaining laboratory results, scheduling appointments, providing health care information, and clarifying medical advice;
5. That the telemedicine services may not be billed to or covered by my insurance or any other third party payor;
6. If I am in a clinic or other facility when seeking services via telemedicine, Provider may collaborate with an on-site clinician to perform the telemedicine services, and it is known and understood that Provider may not be informed of the clinician's knowledge, experiences, and qualifications in rendering such care and makes no representations or warranties regarding such on-site clinician's qualifications;\
7. The quality of transmitted audio/visual communications and related data may affect the quality of services provided by Provider and may result in a disruption of care outside the control of Edward-Elmhurst Health or Provider. Patient assumes the risk for such a disruption of care and agrees, as a condition to accepting services via telemedicine, that neither Edward-Elmhurst Health or Provider is liable for any injuries or damages resulting from such a disruption.
8. In the event that communications are disrupted during treatment via telemedicine. Patient will contact his/her primary care physician for non-emergencies. In the event of a medical emergency or disruption during treatment via telemedicine constituting an emergency, Patient is directed to and agrees to call their local emergency dispatch (usually 911) for follow-up, in­ person medical care, as appropriate;
9. Information may be lost due to technical failures. for which Provider, Edward-Elmhurst Health, and their respective affiliates shall not be held liable;
10. My healthcare information may be shared with other individuals for scheduling, billing, laboratory services, or other related purposes as permitted by HIPAA and other applicable federal and state laws and regulations, and I will provide the name and contact information for a physician of my election for medical records to be forwarded for follow-up care;
11. Patient controls the location from which he/she seeks telemedicine services and assumes the risk of a breach of his/her privacy (i.e. being overheard) by a third party during the telemedicine services.
12. If Patient permits, one or more on-site providers may be present during the consultation in order to operate the telemedicine equipment or assist in rendering services to Patient and will be directed by Provider, at the initiation of telemedicine services, to at all times maintain the privacy and confidentiality of the patient information obtained. To the extent Provider is aware of an on-site provider's presence, Patient will be informed of their presence in the consultation and will have the right to request the following: (1) to omit specific details of my medical history/physical examination that are personally sensitive to me; (2) to ask non­ medical personnel to leave the telemedicine examination room; and/or (3) to terminate the consultation at any time. To the extent Patient permits another person to be present with or overhear Patient during telemedicine services, neither Provider nor Edward-Elmhurst Health or their affiliates shall be liable for such person's subsequent knowledge, use of, or sharing of Patient's protected health information or violation of Patient's privacy and confidentiality rights;
13. The laws that protect the privacy and confidentiality of medical information also apply to telemedicine, and no information obtained in the use of telemedicine which identifies Patient may be disclosed to a third party without Patient's written consent except in a care emergency or as otherwise permitted by applicable law;
14. All patient communications, recordings and records will remain confidential. Systems used for the electronlc communications will incorporate network and software security protocols to protect the confidentiality of patient information and imaging data, and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
15. Despite the security precautions taken by Provider, there is a risk that security protocols could fail, causing a breach of privacy of personal medical information;
16. Telemedicine services may not be provided solely via a phone call, text message, or written correspondence with a provider;
17. Outcomes of this telemedicine consultation cannot be guaranteed or assured; and
18. I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.

By signing this "INFORMED CONSENT FOR TELEMEDICINE SERVICES" form, I, as Patient or Patient's authorized legal representative, hereby give informed consent for the use of telemedicine in Patient's medical care under the terms and conditions described herein and verify that Patient has:

1. Read the whole consent form and fully understands the information provided above regarding telemedicine, including its benefits and risks;
2. Discussed the information contained herein with Provider and had all of his/her questions answered to his/her reasonable satisfaction to make a voluntary, informed decision regarding the use of telemedicine services; and
3. Is located in the State of Illinois during the performance of telemedicine services furnished by Edward-Elmhurst Health or Provider.