Consent for Treatment

As the patient — or as the personal representative of the patient — I consent to the terms and conditions of this agreement. By signing below, I intend that the following apply to all my outpatient care provided by Tellica Imaging, LLC (“Tellica”), an Intermountain Healthcare Company.

The terms “I,” “my,” and “you” in this agreement refer to the patient and to his or her authorized agent or legal representative. The term “Tellica” refers to outpatient care and services provided in facilities owned or operated by IHC Health Services, Inc., Tellica, or by Tellica employees, medical staff, and independent contractors.

Consent to healthcare services

1. I consent to healthcare services provided by Tellica. This includes services I receive provided by Tellica employees, medical staff, and independent contractors. Healthcare services include all healthcare and related medical, diagnostic, and therapeutic services, the implementing of physician orders, and all tests, studies, treatments and procedures ordered and performed in the good faith belief that they are either medically necessary or otherwise appropriate for me under the circumstances. I may be asked to give additional consent for procedures, tests, or treatments that have additional risk.

I understand that:

  • All healthcare services come with some risk, sometimes even the risk of serious harm. I accept this risk in the hope of a good result.
  • • No promise has been made to me concerning a final result, outcome, or cure.
  • Healthcare provider training may occur during my care. Any care provided by a trainee will be under the supervision of my doctor or healthcare team.
  • • I can change my mind or refuse care. If I do, I must tell my healthcare team as soon as possible.

Independent contractors

2. I understand that some of the people providing my care may be independent contractors and not employees or agents of Tellica. I understand that:

• Tellica is not responsible or liable for the judgment, conduct, actions, or inactions of independent contractors.

Some of these people may be employees of the State of Utah. The Utah Governmental Immunity Act controls all claims of liability or malpractice against State employees.

My protected health information

3. Tellica will keep medical records about me confidential, as required by state and federal laws. I have been offered a copy of Tellica’s Notice of Privacy Practices, which describes how medical information about me may be used and shared and my rights including how I can get access to this information. It may be revised from time to time, and I may ask to see a copy at any time.

4. I consent for my health information to be accessed by anyone at Tellica needing it for treatment, payment, or healthcare operations, without further approval from me.

Photographs and video recording

5. I understand that Tellica has the right to take photos or video for security purposes, to help with my care, or to improve quality of care.

6. I agree that I will not take pictures or videos in Tellica facilities without first obtaining the permission of everyone in the image or video. I understand that employees, providers, and others have the right to refuse being included in an image or video.

7. I understand that Tellica may restrict my ability to take photographs, videos, or audio recordings, especially in patient care areas.

Insurance and government payments

8. I consent for Tellica to file for insurance benefits to pay for my care.

I transfer to Tellica (and to any other healthcare provider for whom Intermountain bills) the benefits of any insurance policy or other Tellica that may pay for my care.

I consent for Tellica (and anyone it may assign as my legal representative) to negotiate claims with any insurance company or other payer to obtain payment for services provided to me.

I consent for Tellica to deposit any money received against the charges of the facility (and of any other healthcare provider for whom Tellica bills).

I also specifically assign and transfer to Tellica all rights that are due to me under the Employee Retirement Income Security Act of 1974, 29 U.S.C. Sec. 1001, et seq. (“ERISA”). This shall include, but not be limited to, the right under 29 U.S.C. Section 1132(c)(1) to request plan documents and to recover damages in the event those plan documents are not provided. It shall also include the right to recover interest and attorney’s fees.

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9. I attest that any information I have used to apply for government benefits is correct. This includes Medicare, Medicaid, Tricare, or any other government program.

I consent for Intermountain (or anyone else with medical information needed to process a claim for payment) to share it with government program administrators or any other payer.

• I request these payers to make payments for all these services directly to Tellica.

What I am responsible to pay

10. I, as the patient or as a person signing for the patient who is otherwise legally responsible to pay for the care of the patient (the “Responsible Party”), agree to pay for the following charges:

 • All amounts owed for healthcare services I receive from Tellica, as determined by Tellica or an independent contractor.

 • My share of the costs, including all co-payments, deductibles, and co-insurances that apply.

 • All charges for non-covered services.

 • Interest on unpaid balances that are more than 30 days past due or are sent by Tellica or an independent contractor for collection.

 • A service charge of $20.00 for any check or form of payment that returns unpaid.

 • All costs and attorney fees (if used) Tellica or an independent contractor incurs if either refers my overdue bill for collection.

 • If I am the Responsible Party, I hereby consent to credit bureau inquiries for Tellica’s or the independent contractor’s business needs.

11. I understand that if I am a temporary caregiver for the patient (such as a nanny, youth leader, foster parent or some law enforcement agencies), I may not be financially responsible for the patient’s care. I recognize that this statement about temporary caregivers is not an opinion by Intermountain whether I am or am not a temporary caregiver or whether I am responsible to pay for the patient’s care.

Consent for Credit Bureau Inquiries and Communications

12. I hereby consent to credit bureau inquiries for Tellica’s or the independent contractor’s business needs, and to receiving auto-dialed, artificial, and pre-recorded messages (including text messages) and calls to my cellular phone number and any other telephone numbers provided during any interaction, agreement or communication with Tellica, the independent contractor, the Tellica system and/or their affiliates, agents and contractors, including any account management companies and/or debt collectors. I acknowledge that text communications are not a secure method of communication and accept the risk that my information may be intercepted and read by a third party.

Changes to this consent

13. If I make changes to this consent document, they are not valid.

By using Tellica, I understand and agree to the following:

1. I have had the opportunity to read this agreement or have it read to me and I understand what I am agreeing to.

2. I have had the opportunity to ask questions and I have received satisfactory answers to all my questions regarding this document.

3. I can ask for and get a copy of this agreement.

4. This document will remain in effect unless I revoke it in writing.