CONDITIONS OF ADMISSION/CONSENT FOR TREATMENT

CONDITIONS FOR ADMISSION AND CONSENT FOR CARE

In this document, “Patient” means the person receiving treatment. “Patient Representative”
means any person acting on behalf of the Patient and signing as the Patient’s representative. Use
of the word “I,” “you,” “your” or “me” may in context include both the Patient and the Patient
Representative. With respect to financial obligations “I” or “me” may also, depending on the
context, mean financial guarantor “Guarantor”.
“Provider” means the hospital and may include healthcare professionals on the hospital’s staff
and/or hospital-based physicians, which include but are not limited to: Emergency Department
Physicians, Pathologists, Radiologists, Anesthesiologists, Hospitalists, certain other licensed
independent practitioners and any authorized agents, contractors, affiliates, successors or
assignees acting on their behalf.
Legal Relationship between Hospital and Physicians. Most or all of the physicians performing
services in the hospital are independent and are not hospital agents or employees. Independent
physicians are responsible for their own actions and the hospital shall not be liable for the acts or
omissions of any such independent physicians.
1. Consent to Treatment. I consent to the procedures which may be performed during this
hospitalization or during an outpatient episode of care, including, but not limited to, emergency
treatment or services, and which may include laboratory procedures, x-ray examination,
diagnostic procedures, medical, nursing or surgical treatment or procedures, anesthesia, or
hospital services rendered as ordered by the Provider. I consent to allowing students as part of
their training in health care education to participate in the delivery of my medical care and
treatment or be observers while I receive medical care and treatment at the Hospital, and that
these students will be supervised by instructors and/or hospital staff. I further consent to the
hospital conducting tests including but not limited to, testing for hepatitis, Acquired Immune
Deficiency Syndrome (“AIDS”), and Human Immunodeficiency Virus (“HIV”), if a physician
orders such tests.. I understand that the potential side effects and complications of this testing are
generally minor and are comparable to the routine collection of blood specimens, including
discomfort from the needle stick and/or slight burning, bleeding or soreness at the puncture site.
The results of this test will become part of my confidential medical record. I also certify that no
guarantee or assurances have been made as to the results that may be obtained.
2. Compliance With Hospital Policies And Procedures: I agree to comply with all hospital
policies and procedures, including the hospital "NO SMOKING" policy.

3. Consent to Treatment Using Telemedicine. I consent to treatment involving the use of

electronic communications (“Telemedicine”) to enable health care providers at different
locations to share my individual patient medical information for diagnosis, therapy, follow-up,
and/or education purposes. I consent to forwarding my information to a third party as needed to
receive Telemedicine services, and I understand that existing confidentiality protections apply. I
acknowledge that while Telemedicine can be used to provide improved access to care, as with
any medical procedure, there are potential risks and no results can be guaranteed or assured.
These risks include, but are not limited to: technical problems with the information transmission
or equipment failures that could result in lost information or delays in treatment. I understand
that I have a 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 treatment and without risking the loss
or withdrawal of any program benefit to which I would otherwise be entitled.

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 CONDITIONS OF ADMISSION/CONSENT FOR TREATMENT

4. Consent to Photographs, Videotapes and Audio Recordings. I consent to photographs,

videotapes, digital or audio recordings, and/or images of me being recorded for security purposes
and/or the hospital’s quality improvement and/or risk management activities. I understand that
the facility retains the ownership rights to the images and/or recordings. I will be allowed to
request access to or copies of the images and/or recordings when technologically feasible unless
otherwise prohibited by law. I understand that these images and/or recordings will be securely
stored and protected. Images and/or recordings in which I am identified will not be released
and/or used outside of the facility without a specific written authorization from me or my legal
representative unless otherwise required by law.

5. Financial Agreement. In consideration of the services to be rendered to Patient, Patient or

Guarantor individually promises to pay the Patient’s account at the rates stated in the hospital’s
price list (known as the “Charge Master”) effective on the date the charge is processed for the
service provided, which rates are hereby expressly incorporated by reference as the price term of
this agreement to pay the Patient’s account. Some special items will be priced separately if there
is no price listed on the Charge Master. An estimate of the anticipated charges for services to be
provided to the Patient is available upon request from the hospital. Estimates may vary
significantly from the final charges based on a variety of factors, including, but not limited to,
the course of treatment, intensity of care, physician practices, and the necessity of providing
additional goods and services.

I understand that physicians or other health care professionals may be called upon to provide
care or services to me or on my behalf, but that I may not actually see, or be examined by, all
physicians or health care professionals participating in my care; for example, I may not see
physicians providing radiology, pathology, EKG interpretation and anesthesiology services. I
understand that, in most instances, there will be a separate charge for professional services
rendered by physicians to me or on my behalf, and that I will receive a bill for these professional
services that is separate from the bill for hospital services.
The hospital will provide a medical screening examination as required to all Patients who are
seeking medical services to determine if there is an emergency medical condition without regard
to the Patient’s ability to pay. If there is an emergency medical condition, the hospital will
provide stabilizing treatment within its capacity. However, Patient and Guarantor understand that
if Patient does not qualify under the hospital’s care policy , Patient or Guarantor is not relieved
of his/her obligation to pay for these services.

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 CONDITIONS OF ADMISSION/CONSENT FOR TREATMENT

6. Private Room. I understand and agree that I am (or Guarantor is) responsible for any
additional charges associated with the request and/or use of a private room.

7. Communications About My Healthcare. I authorize my healthcare information to be

disclosed for purposes of communicating results, findings, and care decisions to my family
members and others I designate to be responsible for my care. I will provide those individuals
with a password or other verification means specified by the hospital. I agree I may be contacted
by the Provider or an agent of the Provider or an independent physician’s office for the purposes
of scheduling necessary follow-up visits recommended by the treating physician.

8. Consent to Telephone Calls for Financial Communications. I agree that, in order for you,
and collection staff member, to service my account or to collect any amounts I may owe, I
expressly agree and consent that you or your collection staff member may contact me by
telephone at any telephone number I have provided or, at any number forwarded or transferred
from that number, regarding the hospitalization, the services rendered, or my related financial
obligations.

9. Release of Information. I hereby permit Providers to release healthcare information for

purposes of treatment, payment or healthcare operations. Healthcare information regarding a
prior admission(s) at other facilities may be made available to subsequent admitting facilities to
coordinate Patient care or for case management purposes. Healthcare information may be
released to any person or entity liable for payment on the Patient’s behalf in order to verify
coverage or payment questions, or for any other purpose related to benefit payment.

10. Other Acknowledgements.

Personal Valuables. I understand that the hospital maintains a safe for the safekeeping of money
and valuables, and the hospital shall not be liable for the loss of or damage to any money,
jewelry, documents, furs, fur coats and fur garments, or other articles of unusual value and small
size, unless placed in the safe, and shall not be liable for the loss or damage to any other personal
property, unless deposited with the hospital for safekeeping. The liability of the hospital for loss
of any personal property that is deposited with the hospital for safekeeping is limited to INR
1000 or the maximum INR 2000, unless a written receipt for a greater amount has been obtained
from the hospital by the Patient. The hospital is not responsible for the loss or damage of cell
phones, glasses or dentures or personal valuables unless they are placed in the hospital safe in
accordance with the terms as stated above.

Weapons/Explosives/Drugs. I understand and agree that if the hospital at any time believes
there may be a weapon, explosive device, illegal substance or drug, or any alcoholic beverage in
my room or with my belongings, the hospital may search my room and my belongings located
anywhere on hospital property, confiscate any of the above items that are found, and dispose of
them as appropriate, including delivery of any item to law enforcement authorities.

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 CONDITIONS OF ADMISSION/CONSENT FOR TREATMENT

Patient Visitation Rights. I understand that I have the right to receive the visitors whom I or my
Patient Representative designates, without regard to my relationship to these visitors. I also have
the right to withdraw or deny such consent at any time. I will not be denied visitation privileges
on the basis of age, race, color, national origin, religion, gender, gender identity and gender
expression, and sexual orientation or disability. All visitors I designate will enjoy full and equal
visitation privileges that are no more restrictive than those that my immediate family members
would enjoy. Further, I understand that the hospital may need to place clinically necessary or
reasonable restrictions or limitations on my visitors to protect my health and safety in addition to
the health and safety of other Patients. The hospital will clearly explain the reason for any
restrictions or limitations if imposed.
Additional Provision for Admission of Minors/ Incapacitated Patient. I, the undersigned,
acknowledge and verify that I am the legal guardian or custodian of the minor/incapacitated
patient.

11. Notice of Privacy Practices. I acknowledge that I have received the hospital’s Notice of
Privacy Practices, which describes the ways in which the hospital may use and disclose my
healthcare information for its treatment, payment, healthcare operations and other prescribed and
permitted uses and disclosures. I understand that this information may be disclosed electronically
by the Provider and/or the Provider’s business associates. I understand that I may contact the
hospital office designated on the notice if I have a question or complaint.

12. Consent to Authorize Use of Email and laptop/cell phone. By my consent below, I
authorize the use of any email address or cellular telephone number only for work related or
business purpose and will not provide Laptops/Cell phone to other inmates

13. Acknowledgement of Notice of Patient Rights and Responsibilities. I have been furnished
with a Statement of Patient Rights and Responsibilities ensuring that I am treated with respect
and dignity and without discrimination.
14. Acknowledgement: I have been given the opportunity to read and ask questions and I
acknowledge that I either have no questions or that my questions have been answered to my
satisfaction and that I have signed this document freely and without inducement other than the
rendition of services by the Providers.

IMPORTANT CONSIDERATIONS:

NO ALCO HOL AND NO SMOKING POLICIES

In line with other health care facilities, Spandana health care centre is a smoke free campus
where smoking is not permitted anywhere within its grounds. If you need assistance or advice
with smoking cessation please meet psychiatrist. The use of nicotine patches or nicotine gum
should be reviewed with your doctor prior to use. You can smoke if permitted by family
members only during the fixed timing .You are not allowed to smoke in the ward
rooms/bathrooms/restrooms.The hospital is also an alcohol free campus. If these restrictions are
an issue for you please inform nursing staff.

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 CONDITIONS OF ADMISSION/CONSENT FOR TREATMENT

NO LIFT POLICY
A system for safely moving and mobilising patients is followed at Spandana Healthcare. This
system has been implemented to protect our patients and staff
from injury. We expect to use stair case for safety reason. Lift can be used only by patients who
are not medically fit, unable to climb the staircase. During your stay, please assist us by
cooperating and complying with staff instructions.

EMERGENCY PROCEDURES
There are staff on each ward who are trained in the procedures to follow during emergencies. In
the event of an emergency remain by your bed until a Doctor/staff member advises you what to
do. DO NOT USE THE LIFTS.

PREVENTING PRESSURE INJURY

A pressure injury (also known as a pressure sore or bed sore) is an area of skin that has been
damaged due to unrelieved pressure shearing force or friction. Pressure injuries may look minor,
such as redness on the skin, but they can hide more damage under the skin surface. They usually
occur over bony areas – especially heels, buttocks and toes. Anyone confined to a bed or chair,
who is unable to move, has loss of
sensation, loss of bowel or bladder control, poor nutrition or is unwell is at risk of getting a
pressure injury.

What you can do to prevent pressure injury:

• Move – whether you are lying in bed or sitting in a chair, the best thing you can do to relieve
pressure is to keep active, and change your position frequently. If you are unable to move
yourself, staff will help to change your position regularly. Special equipment such as air
mattresses, cushions and booties may be used to reduce the pressure in particular places.
• Look after your skin – keep your skin and bedding dry. Let staff know if your clothes or
bedding are damp. Tell staff if you have any tenderness or soreness over a bony area or
if you notice any reddened, blistered or broken skin. Avoid massaging your skin over bony parts
of the body. Use a mild soap and moisturise dry skin at least daily. Avoid lanolin based
moisturisers. Aqueous and urea based products are preferred. E.g. Cetaphil and DermaVeen.
• Eat a balanced diet
Ask your nurse or healthcare professional if you would like any more information.
.
PREVENTING FALLS IN HOSPITAL
Falls can be serious, as they can lead to injury and a longer stay in hospital. Your medical
condition may mean that regular activities such as walking, dressing and getting out of bed are
more difficult while in hospital.

Top tips for preventing a fall:

• Ask for help
• Use your call bell
• Take your time
• Inform staff when you are feeling unwell, weak or unstable and sit down
• Walk with the assistance of safety devices such as hand rails, crutches, walkers etc.
• Wear supportive slippers/shoes

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 CONDITIONS OF ADMISSION/CONSENT FOR TREATMENT

RESPONSIBOLITIES OF PATIENT:
 In order to obtain maximum benefit from the rehabilitation Program and to protect the
rights and safety of all participating members, the following set of expectations has been
developed. All patients participating in the program are expected to contract with the
program to follow these guidelines:

 Provide accurate and complete information about present complaints, past illnesses,
hospitalizations, medications and other matters relating to your health
• Report unexpected changes in your condition to the responsible practitioner
• Report if you do not comprehend a contemplated course of action or what is expected of
you
• Follow the treatment plan recommended by the practitioner primarily responsible for your
care. This may include following instructions of nurses and allied health personnel as
they carry out the coordinated plan of care and implement the responsible practitioner’s
orders.
 Where possible you should take an active role in your healthcare and participate as fully
as you wish in the decisions about your care and treatment. We also encourage your
family, other carers or chosen support person to be actively involved. With your consent,
they can also receive information and be involved in making decisions about your care
with you. You should endeavour to follow your treatment, and inform your health
provider when you are not complying with your treatment. You should cooperate fully
with the doctor and clinical team in all aspects of your treatment. You must let staff know
if there are changes to your condition or new symptoms. You should keep appointments
or let the health provider know when you are not able to attend.

 Be as open and honest with staff as you can, including giving comprehensive and
accurate details of your medical history, past surgeries and all medications you may be
taking. Ask questions of staff if you would like more information about any aspect of
your care.

 You are expected to be an active participant in your treatment. The program is

short stay and is aimed at the resolution of acute problems. You agree to:
o Work on setting and achieving realistic and positive goals.
o Be on time and attend all groups and activities for which you are
scheduled.
o Need to take medications as prescribed by the treating psychiatrist.
o Attend the full program between the hours of 9 a.m. and 7 p.m.,.
o You should notify the program if you are unable to attend for any reason. Three or
more unexcused absences will result in a team conference. At that time, continuing in the
program and possible individual interest in another program will be discussed.
o If on any day you are unable to arrive before 10:oo a.m for the activities., negative
reinformcent like cancellation of cigarettes/ delaying of food will be given.
o You must stay on program grounds during the program day.

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 CONDITIONS OF ADMISSION/CONSENT FOR TREATMENT

2. No violence will be tolerated. This includes physical and verbal violence against other
persons and destruction of property. You may be billed for replacement/repair costs.

3. No drinking or use of un-prescribed medications or drugs will be tolerated at any time

(while in the program). This also applies to attending the program activities under the
influence of drugs or alcohol. No alcohol or un prescribed medications are allowed on the
hospital grounds. If hospital stuff becomes aware about you stealing medication from the
nursing station cupboard you may be shifted to old building as a part of negative
reinforcement.

4. You are expected to respect the rights of others in the program and follow the rules of
the hospitals. All information about other patients is strictly confidential and you should
not share your personal information with other inmates during as well as outside the
program.
The program strongly discourages patients from forming personal relationships
that extend beyond the scope of the treatment service, due to the intense vulnerability that
can sometimes develop in this setting. If such relationships do develop, patients are
encouraged to discuss the situation with their attending psychiatrist and with counselor.
Depending on the situation, dismissal from the program may be required to maintain
patient boundaries.

5. Behavior that is disruptive, abusive, or in other ways prevents others from participating
in the program will not be tolerated. This includes:
o Arriving late to the program, late to groups, or leaving early.
o Ridiculing others because of their problems or differences.
o Criticizing others.
o Undermining others’ treatment programs.

6. Cell phones should be turned off or turned to vibrate mode during groups if phones are
permitted by the treating doctor and phone should be used only inside the ward. The
office phone number may be used for emergency contact.
7. Spandana Health care is not responsible for personal property lost or stolen while you
are a participant in the program. Valuable items to be returned to the family members
once you are admitted in the hospital. In case if you keep valuables at our office hospital
is not responsible.
8. Patients are expected to consider their participation in the program as similar to a
job, in which active engagement is necessary, as opposed to a facility in which
treatment is passively received. An active approach is encouraged.

9. A patient’s attending psychiatrist is her/his primary therapist in the program. In

addition, you are expected to get engaged in helping our hospital staff.
 Behaviors that are disruptive to others, dangerous to you, and/or dangerous to others will
result in corrective action and/or discharge from the program and referral to an
appropriate level of care. These behaviors are:
o Psychiatric symptoms disruptive to the group
o Threats of suicide

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 CONDITIONS OF ADMISSION/CONSENT FOR TREATMENT

o Repeated failure to attend scheduled groups

o Possession of contraband including unauthorized medication, alcohol, and
weapons.
o Substance abuse while enrolled in the program but offsite
o Sexual advances towards other patients, staff, or visitors
o Engaging in personal relationship with other patients
o Trading or selling items to other patients
o Repeated violation of group rules (i.e. leaving the room repeatedly, interrupting
others, disrespecting other group members, side conversations, other distracting or
disrespectful behavior).
 Behaviors that will result in automatic immediate discharge from the program or transfer
to an appropriate level of care are:
o Suicide attempts or threats judged to be active/planned, with intent
o Aggression towards staff, patients, or visitors, including verbal threats,
intimidation, and any touching or attempts to touch in an aggressive manner
o Serious self mutilation
o Substance use on site
o Unwanted sexual contact with another patient, even when consensual
o Destruction of property with intent to destroy property, including small things
such as a plant or a plate
o Possession of a lethal weapon such as a gun, knife, gun
o Possession of illicit drugs

10. You are allowed to attend phone calls made by your family members/relatives only.
You can not make phone calls to your friends other than your family members. Once a
week you can make call.

11. You are allowed to use of internet for job search and checking emails only.

12.Only authorized family members can visit me

13. You are not allowed to keep the money with you at any cost. In case, money found
with you , you are requested to submit the money in our office. Kindly make a note of
total amount given at office and receipt is given to you.
14. Your personal belonging like your luggage will be inspected by the social
workers/psychologist/Nurse at reasonable times.

 You should promptly pay the fees of the hospital and your attending doctor.

 Please inform your health professional if you have a current Advance Care Directive or
Power of Attorney for any health or personal matters, or if you are subject to a
guardianship order.
• Provide information concerning your ability to pay for services

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 CONDITIONS OF ADMISSION/CONSENT FOR TREATMENT

• Accept the consequences of your actions if you refuse treatment or do not follow the
practitioner’s instructions
• Be considerate of the rights of other patients and health care facility personnel and for
assistance in the control of noise, smoking and numbers of visitors
• Be respectful of the property of other persons and of the health care facility
• Behave in a lawful manner and contribute to a safe and comfortable environment

Understanding your rights

As a patient of Spandana Healthcare, you have certain responsibilities as a patient and the right
to expect a certain standard of healthcare.

Your Rights
You have the right to:
• Considerate and respectful care, regardless of your beliefs and ethnic, cultural and religious
practices.
• Know the name of the doctor who has primary responsibility for coordinating your care, and
the identity and functions of others who are involved in providing care
• Seek a second opinion and to refuse the presence of any health care workers who are not
directly involved in the provision of your care
• Receive information from your doctor in non-technical language, regarding your illness, its
likely course, the expected treatment, the plans for discharge from the hospital and for follow-up
care
• Receive from your doctor a description of any proposed treatment, the risks, the various
acceptable alternative methods of treatment, including the risks and advantages of each, and the
consequences
of receiving no treatment, before giving consent to treatment. Also, unless the law prohibits, you
may refuse a recommended treatment, test or procedure, and you may leave the hospital against
the advice of your doctor at your own risk after completion of hospital discharge forms
• Participate in decisions affecting your healthcare.
• Be informed of the estimated costs charged by the hospital.
• Refuse participation in any medical study or treatment considered experimental in nature. You
will not be involved in such a study without your understanding and permission.
• Confidentiality and privacy. Details concerning your medical are, including examinations,
consultations and treatment are confidential. No information or records pertaining to your care
will be released without your permission, or the permission of your representative, unless such a
release is required or authorized by law or necessary to enable another health care worker to
assist with your care
• Know, before your discharge from the hospital, about the continuing health care you may
require, including the time and location for appointments and the name of the doctor who will be
providing
the follow-up care.
• Not be restrained, except as authorised by your doctor or in an emergency when necessary to
protect you or others from injury
• The right to retain and use your personal clothing and possessions as space permits, unless to
do so would infringe on the rights of other patients or unless medically contra-indicated.

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 CONDITIONS OF ADMISSION/CONSENT FOR TREATMENT

• Expect safety where practices and environment are concerned

• Privacy for visits during established patient visiting hours
• Make a comment or complaint about the treatment or the quality of the health services or care
without fear that you will be discriminated against
• Have your dietary and other special needs considered

PATIENT COMPLAINT PROCEDURE

While we hope every patient’s visit goes smoothly, it is important that we are notified of patient
concerns so we can take the appropriate steps to address them.
A patient has the right to communicate a verbal or written complaint or concern regarding any
aspect of his/her visit (i.e. medical care, service, conditions, billing) and expect a timely
response. If you have comments, questions or concerns, we recommend that you or your
representative:
• It is always best to try and resolve your complaint with Administrator/Manager.
• If you have tried this and are still unsatisfied, and you believe your questions or concerns have
not been adequately addressed, you may request a review by contacting Medical Director.

I , the undersigned, have read and fully understand the Conditions of Admission and Consent for
Treatment. My signature acknowledges that I have been given the opportunity to satisfy myself
by asking questions about the Conditions of Admission/Consent for Treatment. I voluntarily give
my consent to hospital care, and I accept the conditions of hospital care. I understand that the
practice of medicine is not an exact science and that diagnosis and treatment may involve risks of
injury or even death. I acknowledge that no guarantees have been made to me as to the result of
examination or treatment in this hospital.

Patient Full Name:………………………………………….

Patient Signature……………………………………..Date:…………………………….

Patient’s Representative Name…………………….Date…………………………………..

Patient’s Representative …………………….Date…………………………………..

Relationship if Other than Self Witness……………… Date…………..

Witness Name:………………………………………

Witness
Signature:……………………………………………………Date…………………………………
………….

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