Linden Oaks Business Office - Patient Sign-In Form -2022 with new system General Consent form added Header Image

Patient Information. Sign-In Form

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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Today's Date
Signature of patient (or patient's parent/guardian or personal/legal representative)*
Email address will receive a copy of this form.
Are you a minor under the age of 18 years old?*

Notice of Patient Privacy Practices & Acknowledgement

As a patient, you have certain rights and responsibilities that will help you stay informed  about your condition and understand the treatment you are receiving. In addition, the  NorthShore – Edward-Elmhurst Health Notice  of Privacy Practices describes how medical  information may be used and disclosed, and  how you can get access to this information.  

To view your Notice of Privacy Practices, use  the QR code or URL below.


1. Step 1: View Edward-Elmhurst Heathcare Privacy Practices

2. Step 2: Sign and acknowledge below you have had the opportunity to view our Patient Privacy Practices.


I acknowledge I have had the opportunity to review the Privacy Practices at Linden Oaks Behavioral Health, a part of Northshore | Edward-Elmhurst Healthcare. *
If you have questions prior to agreeing to and signing our Privacy Practices, you can contact the Linden Oaks Business Office at 630-305-5096. Paper copies available upon request.

Patient Rights | Responsibilities & Acknowledgement

As a patient, you have certain rights and responsibilities that will help you stay informed about your condition and understand the treatment you are receiving. In addition, the  NorthShore – Edward-Elmhurst Health Notice of Privacy Practices describes how medical information may be used and disclosed, and how you can get access to this information.  

To view your Patient Rights & Responsibilities, use the QR code or URL below.


1. Step 1: View Edward-Elmhurst Heathcare Patient Rights


2. Step 2: Sign and acknowledge below you have had the opportunity to view our Patient Rights.


I acknowledge I have had the opportunity to review the patient Rights at Linden Oaks Behavioral Health, a part of Northshore | Edward-Elmhurst Healthcare..*
If you have questions prior to agreeing to and signing our Patient Rights you can contact the Linden Oaks Business Office at 630-305-5096.

Consent for Care and Services

CONSENT FOR CARE AND SERVICES

Please read this form carefully. This “Consent” form explains how we provide care, share your information, receive payment for the services provided, and perform certain business functions. Unless it is an emergency, you must sign this form before receiving care. We cannot accept any changes to this form.

 My Consent for Care and General Terms

Who We Are: In this Consent, the term “ENDEAVOR HEALTH” “we” or “us” means:  Edward Hospital, Elmhurst Hospital, Evanston Hospital, Glenbrook Hospital, Highland Park Hospital, Linden Oaks Hospital, Northwest Community Hospital, Skokie Hospital, Swedish Hospital, and any other patient care location (including but not limited to immediate care; walk-in clinics), Endeavor Health Medical Group, and certain other organizations owned or controlled by Edward-Elmhurst Health, Endeavor Health Clinical Operations, and/or its parent ENDEAVOR HEALTH (the “Affiliates”), and the physicians, nurses and other staff or employees or any other Affiliate patient care locations.

Providing Care: I give my consent for ENDEAVOR HEALTH to provide care to me or the person designated below (“me”, “my” or “I”). I understand that care means all medical services, including, but not limited to, examinations, treatment, diagnostic procedures, administration of medications, and/or immunizations deemed necessary and appropriate to treat my condition or illness. If medically needed or requested by me, care may also include mental health evaluation and treatment. If I am pregnant, I agree that all the provisions in this Consent also apply to my unborn child/children or newborn child/children while receiving care from ENDEAVOR HEALTH.

I understand that this form authorizes any reasonable medical action taken for any purpose while I receive care with ENDEAVOR HEALTH, which may include HIV testing, unless I specifically opt-out of the HIV testing by informing my treating provider that I decline such testing. The diagnostic procedures and medical treatment to be provided shall be determined by my physician(s) or other appropriate practitioners, as necessary or advisable at the time treatment is performed. I understand that no guarantees have been made to me about the result of my examination or treatment.

I understand that ENDEAVOR HEALTH’s mission is fostered through the training of healthcare professionals. I agree that physicians, residents, fellows, nurses, technicians, representatives from medical and device manufacturing companies who provide support and other healthcare professionals in-training may be actively involved in my care and treatment.

Language Assistance: If applicable, I have identified my preferred language and whether I require qualified interpreting or other language assistance services during registration. I understand that qualified interpreting and other language assistance services are available to me at no cost and, if I did not elect to have language assistance services at registration, I may request these services at any time during my visit by notifying a member of the patient care team.

Advance Directive: I acknowledge that I have the right to formulate an advance directive and to have ENDEAVOR HEALTH comply with these directives. If I have provided ENDEAVOR HEALTH with a copy of my advance directive, ENDEAVOR HEALTH will honor my expressed wishes and directives as fully and as reasonably possible, and in accordance with Illinois law. My access to care, treatment, and services, however, is not dependent upon whether I have an advance directive.

 Photography and recordings by patients: I understand that I am not allowed to take pictures or to record care or treatment provided by ENDEAVOR HEALTH. To respect the privacy of other patients, I understand that I am also not allowed to take pictures or record other patients.

Photography and recordings by ENDEAVOR HEALTH: I understand that ENDEAVOR HEALTH and my individual provider(s) may need to take photographs, video and/or audio recordings to document a medical condition, help with the diagnosis and/or treatment of a condition, and/or help plan details of care. I give permission for ENDEAVOR HEALTH to take photographs, videos, digital and other images or recordings of me for treatment, education and operational purposes. I also give permission for ENDEAVOR HEALTH to use and disclose non-identifiable images externally for these purposes without additional authorization. Further, I understand that the photo from my State issued ID or Driver’s License will be stored in ENDEAVOR HEALTH’s electronic health record to be used for my protection and identity verification. I understand that all reproduction and all copyrights associated with these images and media are and shall remain the property of ENDEAVOR HEALTH, its successors and/or assigns.

SOME OF MY PHYSICIANS/ HEALTHCARE PROVIDERS MAY NOT BE ENDEAVOR HEALTH AGENTS OR EMPLOYEES: 

 ENDEAVOR HEALTH DOES NOT EMPLOY, CONTROL OR DIRECT THE MEDICAL CARE OF THE INDEPENDENT PHYSICIANS ON ITS MEDICAL STAFFS. I understand that all the physicians treating me at ENDEAVOR HEALTH are independent physicians and are not agents or employees of ENDEAVOR HEALTH, except for the physicians employed by ENDEAVOR HEALTH. By reviewing this paragraph, I understand and agree that I have been notified by ENDEAVOR HEALTH that the physicians from the following physician groups listed in the document titled “Notice of Independent Physicians” are independent physicians and not employed by or acting as agents of ENDEAVOR HEALTH. I also understand that this list may not be all-encompassing of every independent physician or independent physician group. Further, I understand that any healthcare provider at ENDEAVOR HEALTH with the words “Independent Medical Staff” on their I.D. badge means that they are not agents of nor are they employees of ENDEAVOR HEALTH. If the employment status of any physician or healthcare provider is important to me, I promise to ask that physician and/or healthcare provider any questions I may have about their employer and/or their employment status. By initialing below this paragraph and signing this form, I acknowledge that I have read and understand that independent physicians and/or independent healthcare providers are not employed, supervised, or controlled by ENDEAVOR HEALTH. I understand that each of these independent physicians have staff privileges but treat patients based upon their own independent medical judgment and that each independent physician, not ENDEAVOR HEALTH, is solely responsible for the care, treatment, and services that they order, request, direct or provide. I further acknowledge that the employment or agency status of the physicians who treat me is not relevant to my selection of ENDEAVOR HEALTH for my care. I also understand that I will receive a separate bill from each of these independent physicians for their services and I am solely responsible for such bills.

Personal Property: I understand that ENDEAVOR HEALTH is not responsible for the loss, theft, or destruction of my personal property, including valuables that I bring with me to ENDEAVOR HEALTH. I release ENDEAVOR HEALTH from responsibility and liability for the loss, destruction, or theft of any personal property that I bring with me to ENDEAVOR HEALTH.

Property Damage:  I understand that I am responsible and accept liability for any damage to or destruction of ENDEAVOR HEALTH property or property belonging to others that is caused by me.

Expiration and Revocation: If I have rights under the law, I may revoke my permission to share my Health Information (as defined below), and this Consent, by contacting:  

Unless revoked or replaced, this Consent will expire when the patient reaches age 18 or becomes legally permitted to consent. For all other patients legally permitted to consent, this Consent will expire when revoked or replaced. I understand that if I revoke my permission to share my Health Information and/or this Consent, it will not apply to any actions taken or needed to be taken by ENDEAVOR HEALTH while this Consent was effective. 

Using and Sharing My Information

The Law: There is a federal law called the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). This law requires ENDEAVOR HEALTH to protect the privacy and security of its patients’ treatment, contact, and financial information. Taken together, this information is called your “Health Information”. There are also other federal and/or state laws that require ENDEAVOR HEALTH to take additional steps to protect certain categories of Health Information, including, but not limited to, Health Information about behavioral or mental health; developmental disabilities; treatment for substance abuse (alcohol and/or drugs) disorders; genetic testing and counseling; HIV/AIDS; sexual assault/ abuse; sexually transmitted illnesses; pregnancy; birth control; domestic abuse of an adult with a disability; child abuse and neglect.

Patient Rights, Authorization and Notice of Privacy Practices (“NPP”): If my permission is required by law, by signing this form I agree that ENDEAVOR HEALTH may receive, use, and disclose my Health Information as set forth in this Consent and as set forth in the NPP. I understand that I can find more information about my rights to my Health Information, and about how ENDEAVOR HEALTH uses my Health Information, in the NPP. I acknowledge that I have access to the NPP and/or have received a copy of the NPP upon request. I also acknowledge that I received a copy of the Patient Rights and Responsibilities form at the time of my admission or soon thereafter. I further understand that the NPP and the Patient Rights and Responsibilities form are available on ENDEAVOR HEALTH’s website at:

I agree that my permission applies to all of my Health Information in ENDEAVOR HEALTH’s possession, including but not limited to my contact information, diagnostic test results, problem and medication list, medical history, and other clinically relevant data.

I understand that ENDEAVOR HEALTH cannot control how others that receive my Health Information will protect or use my information. I understand that others may not be required by law to protect my Health Information.

I understand that if a patient is between the ages of 12 and 17 years old, Illinois requires that the patient must also give permission by signing this form, as appropriate. 

Purposes for which my Health Information may be shared: I understand that ENDEAVOR HEALTH may receive, use, and disclose my Health Information for the purposes outlined in the NPP. Including but without limiting anything outlined in the NPP, and subject to any additional individual authorizations required by law, ENDEAVOR HEALTH may use and disclose my Health Information for the following purposes listed below:

Immunization Tracking Purposes: I-CARE is an immunization record-sharing computer program developed by the Illinois Department of Public Health. I-CARE helps health care providers record, track and report their patients’ immunizations. Participation is not required. If I prefer not to participate, I can obtain an opt out form at any hospital registration location or at https://www.endeavorhealth.org/icare-optout and can be submitted to any hospital registration location or by mail to HIM Department: 4901 Searle Parkway, Suite 170, Skokie, IL 60076 or by email to HIMServices@northshore.org.

Data Sharing Program Purposes: “Other Providers” may also include my providers participating in data sharing programs such as: Epic CareEverywhere® or other similar data sharing programs not listed here (“Data Sharing Programs”). These Data Sharing Programs allow my providers to exchange my Health Information for treatment purposes, including in emergency situations. I give my permission to ENDEAVOR HEALTH to send and receive my Health Information electronically with my other providers via these Data Sharing Programs. If I prefer not to participate in these Data Sharing Programs or if I have questions, even in an emergency, I must notify ENDEAVOR HEALTH’s HIM by calling (331) 221-0714. If I have previously opted out of Data Sharing Programs no further action is required. I understand that opting out removes me from participation in all Data Sharing Programs across ENDEAVOR HEALTH.

Operational Purposes: I agree that the contact information I give to ENDEAVOR HEALTH, such as telephone numbers and email addresses, may be used by ENDEAVOR HEALTH and third parties acting for ENDEAVOR HEALTH to communicate with me for operational purposes including but not limited to appointment follow up, treatment reminders, patient surveys, and/or collection/billing matters. I agree that such contact information I provide to ENDEAVOR HEALTH may be used by ENDEAVOR HEALTH or those acting on its behalf to communicate with me by telephone (including mobile phone), text (including SMS and MMS messages), or automated or prerecorded messages. If I do not want to receive text messages or phone calls or if I still am receiving the text messages, then I must call:

  • For Edward Hospital, Elmhurst Hospital, and Linden Oaks Hospital: the MyChart Help Line at (630) 527-5070.
  • For Evanston Hospital, Glenbrook Hospital, Highland Park Hospital, Skokie Hospital, Swedish Hospital: the NorthShoreConnect Help Line at (847) 425-3900.
  • For Northwest Community Hospital: the MyChart Help Line at (847) 618-4390.

 I know that I am under no obligation to authorize ENDEAVOR HEALTH, its agents, its affiliates, or its third-party vendors to send me text messages. I may opt-out of receiving these communications at any time by responding STOP to text messages. I understand that it may take, at minimum, five (5) business days for processing. I understand that text message/data rates may apply to text messages sent by ENDEAVOR HEALTH, its affiliates, and its third-party vendors under my cell phone plan. I have an affirmative responsibility to provide ENDEAVOR HEALTH with my correct text/mobile number and I am the primary user and subscriber or have consent from the subscriber for the mobile phone number provided to ENDEAVOR HEALTH. ENDEAVOR HEALTH and/or its third-party vendors disclaim all liability and will not be responsible for any text/mobile messages sent to the text/mobile number I provide. I understand and agree that I may receive information via text messages which may include but is not limited to lab result notification, appointment reminders, procedure reminders, virtual waiting room notifications, medication reminders, diagnostic testing notification, health reminders, marketing messages, surveys, and other healthcare related communications and that message frequency varies.

 Marketing Purposes: I further agree that the contact information I give to ENDEAVOR HEALTH may be used by ENDEAVOR HEALTH and its third parties acting for ENDEAVOR HEALTH to communicate with me for commercial, advertising or marketing activities offered by ENDEAVOR HEALTH. I understand and expressly consent to be contacted by auto-dialed and/or artificial or pre-recorded text messages or telephone calls or voicemails at the number I provided to ENDEAVOR HEALTH. I understand that my consent to the activities in this marketing section is not required as a condition of purchasing or receiving any goods or services from ENDEAVOR HEALTH. If I desire to revoke my consent, or do not want to be contacted for any marketing purposes across ENDEAVOR HEALTH, I must notify ENDEAVOR HEALTH by calling (847) 570-3187 or by email to: marketing@northshore.org.

Research Activities: I understand that ENDEAVOR HEALTH’s mission includes advancing knowledge and scientific discoveries through research. Providers and/ or researchers may contact me to discuss research opportunities that may be of interest to me. It is my decision whether I agree to participate and my consent to participate in research is not required as a condition of receiving any care or services from ENDEAVOR HEALTH. If I prefer not to be contacted about research, I must notify the NorthShore Research Institute by e-mail to researchoptout@northshore.org; or by phone: (224) 364-7100.

By signing this Consent, I understand and agree that ENDEAVOR HEALTH may use and share my excess tissue or body fluid left over after a test and/or a medical procedure my Provider orders for its educational and research purposes internally and with research partners, including companies, in accordance with law.

Financial Acknowledgments

Payment for Care: I understand that by signing this form, I agree that ENDEAVOR HEALTH will bill my health insurance for the cost of my care. In exchange for the care provided, I assign and transfer and set forth my rights, title, and interest to any and all medical reimbursement under my insurance policy, subscription certificate or other health benefit coverage agreement otherwise payable to me to ENDEAVOR HEALTH.

I give my permission for ENDEAVOR HEALTH to release all medical information, including HIV related information, which may be necessary for the payment on my behalf for the health care services rendered to the patient named in this Consent.

I understand that insurance coverage varies and that my insurer may not pay for everything or may pay only part of my bill. I understand that my insurer may deny payment for services that are not covered by my plan, or that the insurer decides are not “medically necessary,” “experimental,” or not covered. While ENDEAVOR HEALTH may take reasonable steps to appeal these denials, I understand that I am fully responsible for payment of all charges not covered by medical insurance.

I agree that I am responsible for any expense of ENDEAVOR HEALTH in collecting the amounts guaranteed hereby, including all court costs, reasonable attorneys’ fees, and all other expenses. I authorize ENDEAVOR HEALTH to file a lien, or any other action permitted under Illinois law, to obtain full payment for the services provided.

Billing Providers: As required by the Fair Patient Billing Act, I understand that care and services provided at any ENDEAVOR HEALTH facility may include any of the ENDEAVOR HEALTH and Affiliates providers, including all of their physicians, nurses, and staff. I understand that each provider may bill me separately.

 I understand that ENDEAVOR HEALTH cannot guarantee that a service will be covered under my health plan. I understand that it is my responsibility to contact my insurance company to determine whether a provider or hospital service will be covered by my insurance. I also understand that I should ask my physician any questions I may have about his/her employment status with ENDEAVOR HEALTH and whether he/she participates in the same insurance plans as ENDEAVOR HEALTH. I understand that if I receive “out-of-network” services, I may have greater financial responsibility to ENDEAVOR HEALTH for payment for these services.

I understand that even if a service is covered, or partially covered, by my insurance plan, I may still be responsible for part of the cost. It is my responsibility to contact my insurance company to determine the cost of the service I will be required to pay.

ERISA: If my insurance benefits are provided through an ERISA plan or other employer group health plan, and if permitted under the plan terms, I assign, transfer, and set forth all my rights, title, and interest as a beneficiary of the plan to ENDEAVOR HEALTH, for my care. I also appoint ENDEAVOR HEALTH as my authorized representative to receive plan coverage information and appeal any rights to payment and healthcare benefits. I agree to cooperate and provide information as needed by ENDEAVOR HEALTH to establish my eligibility for my insurance benefits.

Medicaid/Medicare: If I am seeking services to be covered under Medicare or Medicaid, I certify that the information given by me is correct. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for provider services to the provider(s) or organization furnishing the services or authorize them to submit a claim to Medicare or Medicaid on my behalf.

Financial Assistance: If I do not have health insurance or have difficulty paying my bill, ENDEAVOR HEALTH provides eligible patients with financial assistance options, including free care, discounted care, or interest-free payment plans. Information about financial assistance, qualification criteria and whether or not my physician or other providers offer financial assistance is available to me upon request by calling the following numbers:

  • Edward, Elmhurst, and Linden Oaks Behavioral Health hospitals at: (866) 756-8348
  • Evanston, Skokie, Glenbrook and Highland Park hospitals at: (847) 570-5000;
  • Swedish Hospital at (773) 878-8200, extension 3841; or
  • Northwest Community Hospital at: (847) 618-4542.

 By signing below, I confirm that I have read, understood and agreed to the contents of this form, the Consent, including the specific language related to independent physician services. I have been able to ask questions, and all of my questions have been answered to my satisfaction.

 This Agreement is written in English. If this Agreement is translated into any other language, the English version shall control. All required signatures must be provided for the form to be valid: 

                             CONSENT (1/2/2024)      Form#:

Patient Date of Birth - Copy*
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Notice of Independent Physicians

By signing this document, I understand and agree that I have received notice from ENDEAVOR HEALTH that the physicians from the following physician groups listed alphabetically below are independent physicians and not agents or employees of ENDEAVOR HEALTH. I also understand that this list may not be all-encompassing of every independent physician or physician group.

  • Advanced Pain and Spine Management
  • Advanced Women's Health Services
  • Arlington Ridge Pathology, S.C.
  • Associated Pathology Consultants of Elmhurst, S.C.
  • Associates in Nephrology, S.C.
  • Chicago Institute of Advanced Surgery
  • Children's Memorial Medical Group, LLC
  • Childrens Surgical Foundation Inc.
  • Consultants in Kidney Disease, LLC
  • Critical Care Physicians of Illinois, LLC d/b/a Sound Physicians of Illinois ("TIG")
  • Diagnostic Radiology Specialists, S.C.
  • Duly Health & Care f/k/a DuPage Medical Group
  • DuPage Neonatology Associates, S.C.
  • DuPage Valley Anesthesiologists, LTD
  • Elmhurst Anesthesiologists, P.C.
  • Elmhurst Medical Associates Laboratory & Pathology Diagnostics, LLC
  • Elmhurst Memorial Physician Service (EMPS)
  • Elmhurst Radiologist, S.C.
  • Erie Family Health Centers
  • Humayun Medical Associates, S.C.
  • Illinois Kidney Care, PLLC
  • Infectious Disease Consultants Ltd.
  • Intent Medical Group
  • Kidney Specialists of Illinois, LLD
  • KidneyDocs
  • Midwest Anesthesia Partners LLC
  • Midwest Retina Consultants, S.C.
  • Metro Chicago Surgical Oncology, LLC
  • Nephrology Associates of Northern IL, Ltd.
  • Northwest Neurology Ltd.
  • Northwest Radiology Assoc.
  • Northwest Suburban Medical
  • OBGH Management Services, LLC
  • Orthopedic Specialists, S.C.
  • Osipova Surgical Services Corp
  • Radiation Oncology Associates, LLC
  • SCH Laboratory Physicians, S.C.
  • Stellar Pain and Spine Specialists, PLLC
  • Tapestry 360 Health
  • UroPartners, LLC
  • Vituity Healthcare
  • Woman Care, P.C.
Use your mouse or finger to draw your signature above. Witness to signature is implied due to secure method of obtaining signature.
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Signature of Minor Patient (age 12 to age 17) . Disregard if not applicable.
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Informed Consent for Telemedicine Services - Illinois

Introduction:

Telehealth 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 at the time of services being rendered. Telehealth also enables healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. By signing this telehealth consent form (“Consent”), I, as patient or patient’s legal representative, (“Patient”, “I”,”me”, or “my”) consent to the utilization of telehealth technologies in the course of my medical treatment and authorize ENDEAVOR HEALTH (“ENDEAVOR HEALTH” “we” or “us”), which in this Consent means: Edward Hospital, Elmhurst Hospital, Evanston Hospital, Glenbrook Hospital, Highland Park Hospital, Linden Oaks Hospital, Northwest Community Hospital, Skokie Hospital, Swedish Hospital, and any other patient care location (including but not limited to immediate care; walk-in clinics), Endeavor Health Medical Group, and certain other organizations owned or controlled by Edward-Elmhurst Health, Endeavor Health Clinical Operations, and/or its parent ENDEAVOR HEALTH (the “Affiliates”), and the physicians, nurses and other staff or employees or any other Affiliate patient care locations, including but not limited to primary care practitioners, specialists, and/or subspecialists, its staff, independent physicians (as described below), and subcontractors (collectively, “Providers”) to provide Patient with telehealth services and to review and exchange medical information about Patient for the purpose of Patient’s treatment via telehealth. I also acknowledge that insurance coverage for telehealth services varies. Some payors may not cover certain telehealth services at all or may not cover telehealth services to the same degree as in-person services.

SOME OF MY PHYSICIANS/ HEALTHCARE PROVIDERS MAY NOT BE ENDEAVOR HEALTH AGENTS OR EMPLOYEES: 

ENDEAVOR HEALTH DOES NOT EMPLOY, CONTROL OR DIRECT THE MEDICAL CARE OF THE INDEPENDENT PHYSICIANS ON ITS MEDICAL STAFFS. I understand that all the physicians treating me at ENDEAVOR HEALTH are independent physicians and are not agents or employees of ENDEAVOR HEALTH, except for the physicians employed by ENDEAVOR HEALTH. By reviewing this paragraph, I understand and agree that I have been notified by ENDEAVOR HEALTH that the physicians from the following physician groups listed in the document titled “Notice of Independent Physicians” are independent physicians and not employed by or acting as agents of ENDEAVOR HEALTH. I also understand that this list may not be all-encompassing of every independent physician or independent physician group. Further, I understand that any healthcare provider at ENDEAVOR HEALTH with the words “Independent Medical Staff” on their I.D. badge means that they are not agents of nor are they employees of ENDEAVOR HEALTH. If the employment status of any physician or healthcare provider is important to me, I promise to ask that physician and/or healthcare provider any questions I may have about their employer and/or their employment status. By initialing below this paragraph and signing this form, I acknowledge that I have read and understand that independent physicians and/or independent healthcare providers are not employed, supervised, or controlled by ENDEAVOR HEALTH. I understand that each of these independent physicians have staff privileges but treat patients based upon their own independent medical judgment and that each independent physician, not ENDEAVOR HEALTH, is solely responsible for the care, treatment, and services that they order, request, direct or provide. I further acknowledge that the employment or agency status of the physicians who treat me is not relevant to my selection of ENDEAVOR HEALTH for my care. I also understand that I will receive a separate bill from each of these independent physicians for their services and I am solely responsible for such bills.

Notice of Independent Physicians

 

By signing this document, I understand and agree that I have received notice from ENDEAVOR HEALTH that the physicians from the following physician groups listed alphabetically below are independent physicians and not agents or employees of ENDEAVOR HEALTH. I also understand that this list may not be all-encompassing of every independent physician or physician group.

  • Advanced Pain and Spine Management
  • Advanced Women's Health Services
  • Arlington Ridge Pathology, S.C.
  • Associated Pathology Consultants of Elmhurst, S.C.
  • Associates in Nephrology, S.C.
  • Chicago Institute of Advanced Surgery
  • Children's Memorial Medical Group, LLC
  • Childrens Surgical Foundation Inc.
  • Consultants in Kidney Disease, LLC
  • Critical Care Physicians of Illinois, LLC d/b/a Sound Physicians of Illinois ("TIG")
  • Diagnostic Radiology Specialists, S.C.
  • Duly Health & Care f/k/a DuPage Medical Group
  • DuPage Neonatology Associates, S.C.
  • DuPage Valley Anesthesiologists, LTD
  • Elmhurst Anesthesiologists, P.C.
  • Elmhurst Medical Associates Laboratory & Pathology Diagnostics, LLC
  • Elmhurst Memorial Physician Service (EMPS)
  • Elmhurst Radiologist, S.C.
  • Erie Family Health Centers
  • Humayun Medical Associates, S.C.
  • Illinois Kidney Care, PLLC
  • Infectious Disease Consultants Ltd.
  • Intent Medical Group
  • Kidney Specialists of Illinois, LLD
  • KidneyDocs
  • Midwest Anesthesia Partners LLC
  • Midwest Retina Consultants, S.C.
  • Metro Chicago Surgical Oncology, LLC
  • Nephrology Associates of Northern IL, Ltd.
  • Northwest Neurology Ltd.
  • Northwest Radiology Assoc.
  • Northwest Suburban Medical
  • OBGH Management Services, LLC
  • Orthopedic Specialists, S.C.
  • Osipova Surgical Services Corp
  • Radiation Oncology Associates, LLC
  • SCH Laboratory Physicians, S.C.
  • Stellar Pain and Spine Specialists, PLLC
  • Tapestry 360 Health
  • UroPartners, LLC
  • Vituity Healthcare
  • WomanCare, P.C.


Providing Care:

I understand that Patient medical information may be used by Providers for interpretation, evaluation, diagnosis, treatment, 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 Telehealth Services:

  • Improved access to medical care by enabling a patient to remain in his/her location while the healthcare provider interprets, evaluates, diagnoses, and treats the patient at distant/other sites.

Possible Risks of Telehealth Services: 

As with any medical procedure, there are potential risks associated with the use of telehealth 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 (e.g. broadcast and reception problems, including poor picture or sound quality, dropped connections or audio interface), 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 telehealth encounter.
  • As with any internet-based communication, there is a risk that 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.

Messaging Disclaimer

As with telephone messages and non-synchronous communications, messages sent through ENDEAVOR HEALTH messaging portals, such as MyChart or NorthShoreConnect may have certain limitations and I, as Patient, acknowledge and affirm that:

Informed Consent for Telehealth Services 

By signing this Consent 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 telehealth.

2. Telehealth 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 telehealth consultation are available and Patient will have an opportunity to discuss them and concerns with Provider when initiating telehealth services;

4. The types of activities that are permitted and covered using telehealth services are sometimes limited and vary 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. As required by the Fair Patient Billing Act, I understand that care and services provided through any ENDEAVOR HEALTH facility may include any of the ENDEAVOR HEALTH and Affiliates providers, including all of their physicians, nurses, and staff. I understand that each provider may bill me separately.  Some third-party payors may not cover telehealth services at all or may not cover telehealth services to the same degree as in-person services and that ENDEAVOR HEALTH cannot guarantee that a service will be covered under my third-party payor.  I understand that it is my responsibility to contact my insurance company to determine whether telehealth services will be covered by my insurance.  I also understand that I should ask my physician any questions I may have about his/her employment status with ENDEAVOR HEALTH and whether he/she participates in the same insurance plans as ENDEAVOR HEALTH. I understand that if I receive “out-of-network” services, I may have greater financial responsibility to ENDEAVOR HEALTH or Provider for payment for these services. By signing this Consent, I understand and agree that Provider and/or ENDEAVOR HEALTH may separately bill my third-party payor for the cost of my care, and I may be responsible for payment of all charges not covered by my third-party payor, as presented to me.  In exchange for the care provided, I also agree to assign and transfer and set forth my rights, title and interest to any and all reimbursement under my insurance policy to Provider.

6. MEDICAID Patients: Notwithstanding anything to the contrary in this Consent, I understand that if I am an Illinois Medicaid patient that many services provided through telehealth are not covered by Illinois Medicaid and therefore no payment may be made by Illinois Medicaid.  Non-covered services include telehealth visits that occur from a location where I am not physically with a physician, licensed health care professional or other licensed clinician during my entire visit (e.g., not covered from my home or workplace), e-visits, and virtual check-ins.  Therefore, I understand that I may be responsible for the costs of any service that I receive through telehealth.  

7. If Patient is in a clinic or other facility when seeking services via telehealth, Provider may collaborate with on-site personnel to perform the telehealth services, and it is known and understood that Provider may not be informed of the personnel’s knowledge, experiences, and qualifications in rendering such care and makes no representations or warranties regarding such on-site personnel’s qualifications.

8. 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 ENDEAVOR HEALTH or Provider. Patient assumes the risk for such a disruption of care and agrees, as a condition to accepting services via telehealth, that ENDEAVOR HEALTH and/or Provider are not liable for any injuries or damages resulting from such a disruption.

9. In the event that communications are disrupted during treatment via telehealth, Patient will contact his/her primary care physician for non-emergencies, as appropriate. In the event of a medical emergency or disruption during treatment via telehealth 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.

10. Information may be lost due to technical failures, for which Provider and/or Endeavor Health shall not be held liable.

11. 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.

12. Patient controls the location from which he/she seeks telehealth services and assumes the risk of a breach of his/her privacy (i.e. being overheard) by a third party during the telehealth services.

 13. If Patient permits, one or more on-site personnel may be present during the consultation at Provider’s location in order to operate the telehealth equipment or assist in rendering services to Patient and will be directed by Provider, at the initiation of telehealth services, to at all times maintain the privacy and confidentiality of the patient information obtained. To the extent Provider is aware of on-site personnel’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 telehealth 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 telehealth services, Provider and/or ENDEAVOR HEALTH shall not 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.

14. If Patient or Patient’s legal representative requests to add a third-party to Patient’s telehealth visit, Provider is expressly permitted, and not otherwise limited, to discuss Patient’s medical history and medical care, which may include, HIV-status, behavioral/mental health, or substance abuse information. To the extent that Patient does not want such third-party to be present, Patient or Patient’s legal representative may request the third-party to leave the platform and/or ask for a new appointment to which the third-party is not invited.

15. The laws that protect the privacy and confidentiality of medical information also apply to telehealth, and no information obtained in the use of telehealth which identifies Patient may be disclosed to a third party, without Patient’s written consent except in a care emergency, as allowed in this Consent as well as the applicable ENDEAVOR HEALTH general consent, including, without limitation for data sharing program purposes, operational purposes, and for payment,  and/or as otherwise permitted by applicable law.

16. All patient communications, recordings and records will remain confidential. Systems used for the electronic 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.

17. Despite the security precautions taken by Provider or ENDEAVOR HEALTH, there is a risk that security protocols could fail, causing a breach of privacy of personal medical information.

18. Telehealth services may be provided through interactive telecommunication systems which include audio and video systems, an audio-only telephone system (landline or cellular), or any other telecommunication system permitting 2-way, e-visit check-ins, virtual check-ins, synchronous interactive communication between a patient and healthcare provider located at different locations.

19. Outcomes of this telehealth consultation cannot be guaranteed or assured; and

20. I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.

21. Unless this Consent is replaced by ENDEAVOR HEALTH or revoked by me, this Consent will expire no later than one (1) year from the date I accepted this Consent. ENDEAVOR HEALTH will not be able to provide me telehealth services if I do not sign the most current Telehealth Consent, if I revoke the consent, or if this Consent expires. To revoke please contact: 331-221-6936.  My revocation of the consent does not apply to any ENDEAVOR HEALTH actions done in reliance of this consent prior to my revocation.

22. I UNDERSTAND AND AGREE THAT I WILL AT ALL TIMES BE LOCATED IN THE STATE OF ILLINOIS DURING ANY TELEHEALTH SERVICE FURNISHED BY PROVIDER OR ENDEAVOR HEALTH AND I WILL BE SOLELY RESPONSIBLE FOR ANY AND ALL DAMAGES, INCLUDING BUT NOT LIMITED TO FINES, AND PENALITIES, THAT MAY BE ASSESSED AGAINST PROVIDER OR ENDEAVOR HEALTH FOR NOT COMPLYING WITH THIS PROVISION.

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

  • Has read the whole Consent form and fully understands and agrees to the information provided above regarding telehealth, including its benefits and risks;
  • Has 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 telehealth services; and                             
  • Is located in the State of Illinois during the performance of any telehealth services furnished by ENDEAVOR HEALTH and/or Provider.   

Signatures

Patient Consent to the Use of Telehealth 



I have read the Telemedicine section of this form. I understand and agree to its contents. *
If you have questions prior to agreeing to and signing our Telemedicine Consent, you can contact the Linden Oaks Business Office at 630-305-5096.
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Signature of Minor Patient (age 12 to age 17)
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If the patient's parent/guardian or personal/legal representative, completed the above signature, what is your name?
By signing below, I confirm that I have read, understood and agreed to the contents of this form, the Consent, including the specific language related to independent physician services. I have been able to ask questions, and all of my questions have been answered to my satisfaction. This Agreement is written in English. If this Agreement is translated into any other language, the English version shall control. All required signatures must be provided for the form to be valid:*
If you have questions prior to agreeing to and signing the Authorizations and Agreements section, you can contact the Linden Oaks Business Office at 630-305-5096.
If the patient's parent/guardian or personal/legal representative, completed the above signature, what is your relationship to the patient
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State of Illinois Rights of Individuals Receiving Mental Health and Developmental Disabilities Services

The State of Illinois requires that you complete an acknowledgement of your rights when receiving mental health services.  Here are the steps to complete this acknowledgement.

  1. Download this State of Illinois Department of Human Services form:
    Rights of Individuals Receiving Mental Health and Disability Services Form

  2. Read these rights.

  3. Complete signature section below indicating you acknowledge you viewed this form. 
If the patient's parent/guardian or personal/legal representative, completed the above signature, what is your relationship to the patient
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Patient Date of Birth*
Sign if other than patient. Use your mouse or finger to draw your signature above
If the patient's parent/guardian or personal/legal representative, completed the above signature, what is your relationship to the patient?
Use your mouse or finger to draw your signature above. Minor Patients: If the patient is 12-17 years of age and the patient’s parent/legal Guardian is authorizing the use and disclosure of the patient’s mental health records, the signature of the minor patient is also required.
Location of Patient in Illinois*
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