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SERVICE BEGINS 3::J 4::J 120 WEST EIGHTH STREET - TELEPHONE 785 88S-4274
ONAGA, KANSAS 56521
5 ::J ::JCritical
DISPOSITION TIME Care , OUTPATIENT
No:J
Please pnnt clearly.
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I SECONDARY INSUf'ANCE COMPANY AND ADDRESS POLICY NO. SUBSCR~ERNAMEANDSSN EMPLOYER ADDRESS AND TELEPHONE I
~ I
CLOSEST RELATIVE. ADDRESS AND TELEPHONE PARTY RESPONSIBLE FOR PAYMENT ADDRESS AND TELEPHONE
Q..,..l 1. CONSENT FOR EXAM AND TREATMENT. This is to certify that I (We) the undersigned, consent to the performance of an examination and to the
---fff- treatment which may be deemed necessary in the opinion of the attending physician.
2 AUTHORIZATION TO PAY INSURANCE BENEFITS. I hereby authorize payment directly to the Community Hospital Onaga, Inc. of the benefits otherwise
h/. (). payable to me but not to exceed the Hospital's regular charges for this period of treatment. I understand that I am financially responsible to the
---'AT Hospital for charges not covered by this authorization.
C, /".J.) 3. AUTHORIZATION TO RELEASE INFORMATION. I hereby authorize Community Hospital Onaga, Inc. to release my medical records or any othe'
~ information requested by my insurance company in reference to this claim.
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P~YS:CiANS SIGNATURE NURSE'S SIGNATURE
I Date Patient Na ! I ' r.. .cal Record Nwnber
I };)-15""OO Do~bnJvJskl) E;!Ci&1Of,'nc .
, PATIENT CONDITIONS ..
I ~ The individU.'l1!us been stabilized such that \.\Iithinreasonable medical probability, no material deteriorntion of L1elJldiYlCU.'l
l'
concitlOn or the condition of the mother llIld/or W1bornchild{ren) is likely to re:ru.ltfrom the tnutsfc:r.
The lIldividual's condition has not stabilized., how~ver, the individual wIll benefit from a transfer to another facility which
outweIghs the nsks associated \.\lithtransfer.
- The :ndiV1dllillis lIlllctive labor. The expected benefits oftr.lnsfer outweigh the potential risks to the mother and/or unborn
chiici(ren).
-;t Rccci\io~ h05pital ha5 agreed to accept transfer and to provide appropriate :10
'pace and penonne!. Name of hospital :md penonnel contacted. G
9\Report given to recehing phY5ician: J:jfl
.ljA-1M,,31.A.e &1 By:'
(NM1E OF PHYSfCIAXiREtEIVING REPORn ,I, I. (TRANS~ERRING PHYSICIAN)
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Sjgn;~.u,'Ire f IndhiduaJ
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or Legally Re5poo5ible Indhidual
k~Q/Qt"- /J~ Witness
tv
~ Date 1:2 - / ')~ - 0 D
Reiauo hip to IndivldUJ..l
! Rl5k llnd Beoefit3: ! have t:xplarned to the lIldividu.all1egally responsIble person L'1efoilov,1ng nsk and benefits of being trarufe:-:-e-"J
! refusmg transfe:.
Based on t.he re.1.Sonablensks and ber.efits to the mdividuaJ and/or the W1bom childirenl, and the !nformauon available at :.'1e::.le or :",",e
lIldivlduaJ's e:'..J.ffilI1atlon.che m~ber.e:its reasonably expected from L~eprOV1Slonof approunale medical treatment at anoL'1er:i"1eere..::.l
(ac:iirv outWC1gJJSthe lIlCTea.sednsks. lfanv, to the:n . , "s m ,A i condition from t:tTetllIlg L'1e:ransfer.
~l------ _(~
'[ :r:msfcr e;f ~lIS mdi vldu.:Jirs ~err,2 made t-er..,,:lUSC th> (j t, II phv IClan railed or re!~sed to Jppe.'1I \'.1thm a reasonClb!e ,\::r-:c-jCI :"'::.
JISt rh1r pn\'SlC:~ 's r.arne md :;c.idIcss he:-e"
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