{"content":[{"text":"GENESIS HEALTHCARE ASSOCIATES, P.C","bbox":{"left":0.291471,"top":0.027489,"width":0.460062,"height":0.022914000000000004}},{"text":"Registration Agreement \n Consent To Treat","bbox":{"left":0.435882,"top":0.102909,"width":0.187805,"height":0.04142399999999999}},{"text":"I.","bbox":{"left":0.120882,"top":0.157076,"width":0.010539000000000007,"height":0.020212000000000008}},{"text":"CONSENT FOR TREATMENT: I consent to such routine diagnostic and treatment procedures/examinations and \n laboratory procedures considered reasonably necessary for the care and treatment of my condition during my care \n at Genesis Healthcare Associates. I understand that diagnostic and treatment procedures involving material risks \n will be explained to me and that I will have the opportunity to ask questions concerning the associated risks, \n alternatives, and prognosis before allowing the procedures to be performed.","bbox":{"left":0.179706,"top":0.160426,"width":0.747279,"height":0.074763}},{"text":"II.","bbox":{"left":0.120882,"top":0.248002,"width":0.014509000000000008,"height":0.015967999999999982}},{"text":"INDEPENDENT CONTRACTORS: I understand that some of the health care professionals providing care, \n treatment and services at Genesis Healthcare may be independent contractors, and not agents or employees of \n Genesis Healthcare. Independent contractors are responsible for their own actions and Genesis Healthcare shall \n not be liable for the acts or omissions of any such independent contractor.","bbox":{"left":0.179706,"top":0.248002,"width":0.7472920000000001,"height":0.05938199999999999}},{"text":"III.","bbox":{"left":0.120882,"top":0.320426,"width":0.019795999999999994,"height":0.015967999999999982}},{"text":"ASSIGNMENT OF BENEFITS/FINANCIAL AGREEMENT AND APPOINTMENT OF REPRESENTATIVE: If I am \n entitled to benefits under the Medicare program, the Medicaid program, or any insurance policy or other health \n benefit plan (covering me or anyone legally responsible for me), in consideration for services provided to me by \n Genesis Healthcare, I assign, transfer, and convey to Genesis Healthcare the benefits payable under such program, \n policy, or plan for services provided to me. I authorize payment of benefits directly to Genesis Healthcare, with \n such benefits to be applied to my bill. I understand and acknowledge that this assignment does not relieve me \n of financial responsibility for charges incurred by me or anyone on my behalf, and I hereby acknowledge \n responsibility for and agree to pay charges not paid under this assignment, including any coinsurance \n amounts and deductibles and any charges for services deemed to be non- covered, not pre-certified, or not \n preauthorized by my insurance plan.","bbox":{"left":0.179706,"top":0.320426,"width":0.747408,"height":0.14699600000000002}},{"text":"If my health care benefits are provided under a self-funded plan under the Employee Retirement Income Security \n Act (ERISA), in order to assist me in obtaining my benefits, I authorize and appoint Genesis Healthcare to act as \n my representative, when Genesis Healthcare consents in writing to so act, in appealing any adverse benefit \n determination and to receive notices on my behalf with respect to the same. I agree that I will comply with \n procedures established by my benefit plan relating to this authorization, if any.","bbox":{"left":0.179706,"top":0.480047,"width":0.74232,"height":0.07392299999999996}},{"text":"IV.","bbox":{"left":0.10902,"top":0.567396,"width":0.020704,"height":0.015967999999999982}},{"text":"CONSENT FOR DISCLOSURE OF INFORMATION: I understand that Genesis Healthcare is permitted to disclose \n protected health information about me for purposes of payment, my continued care or treatment, and healthcare \n operations. If my protected health information includes any records containing information related to the \n treatment of any infectious disease (including AIDS confidential information), drug or alcohol abuse and/or \n mental illness, I hereby consent to the disclosure of this information by Genesis Healthcare only as reasonably \n necessary to accomplish the purposes described above, and I waive any privileges with regard to such disclosure. I \n understand this consent permits release of the identified information to any insurance company, healthcare plan or \n any other person or entity financially responsible for my treatment if necessary or purposes related to filing a \n claim for payment, or, if I am being evaluated for the purposes of determining eligibility, and to my referring \n physician and any health care practitioner, nursing home, health care facility, ambulance service, home health \n agency, government or private agency which may provide medical, mental health, rehabilitation, social or related \n services to me during or upon my transfer from Genesis Healthcare.","bbox":{"left":0.179691,"top":0.567396,"width":0.7475339999999999,"height":0.175296}},{"text":"I understand my consent to disclosure of information related to treatment of any infectious disease (including \n AIDS confidential information) drug or alcohol abuse, or mental illness is valid until all bills related to my \n treatment have been paid and utilization and/or quality assessment have been completed. I further understand \n I can withdraw my consent for disclosure of such information at any time except to the extent action has been \n taken in reliance upon such consent.","bbox":{"left":0.179706,"top":0.756108,"width":0.747169,"height":0.07369700000000001}},{"text":"AGREEMENT TO ALTERNATIVE DISPUTE RESOLUTION: I agree that any claim or dispute arising out of or \n related to the provision of health care services to me by Genesis Healthcare, or its employees or agents, except as \n otherwise provided herein, shall be resolved by final or binding arbitration. I agree that this provision is governed \n by the terms of the Federal Arbitration Act. I understand and agree that this agreement includes and encompasses","bbox":{"left":0.179703,"top":0.847699,"width":0.7473910000000001,"height":0.059382000000000046}},{"text":"1","bbox":{"left":0.52451,"top":0.940881,"width":0.007745000000000002,"height":0.015967999999999982}},{"text":"RG Consent 002 6/2018","bbox":{"left":0.706373,"top":0.939669,"width":0.15786699999999987,"height":0.015967999999999982}}],"images_bbox":[],"images_bbox_not_text_overlap":[]}