HOLLY JpOD PALMS CONVALESCENT jfOSPITAL
ADMISSION t GREEMENT ^
1. You are authorized to perform all services and treatments as prescribed by
Dr. <^'<y/w^ •J^nvfK'it: You may call him at your discretion. If he is
not available, and no one is on call for him, you may call another physician.
2. We understand you provide general duty nursing service. If the patient is in
such condition as to need continuous or special duty nursing, private duty nurses
acceptable to you shall be employed and paid by the patient or guarantor. If you
deem it necessary, the patients accommodations may be changed.
3. Hollywood Palms shall incur no liability for injuries of any kind suffered by the
patient while under its care, except when the injury is caused by negligence of
your employees. If for any reason the patient leaves or is removed from the
premises, you shall not be responsible for the welfare of the patient during such
absence. The patient shall not leave or be removed from the premises without
first notifying the management.
4* Hollywood Palms shall not be responsible for any money, valuables, documents,
furs, clothing, dentures, eyeglasses, hearing aids or any other personal property retained in the patient1 s possession.
5. No foodstuffs, liquids, medical supplies or medicines shall be given the patient
or brought onto the premises for the patient without prior permission.
6. The patient and/or guarantor shall pay $ 7/ j ^/ every in advance,
commencing as of . This fee includes room, meals prescribed, special diets, nourishments, routine linens and 24 hour nursing care.
7. The patient and/or guarantor shall pay promptly when billed for extra materials
or services, such as drugs, x-rays, laboratory tests, hand feeding, incontinence,
extra linens, rental of equipment ordered for the patient's exclusive use, personal supplies and other things deemed necessary for the health and comfort of
the patient. Schedule of fees may be consulted in the office. Should the account
be referred for collection, the patient and/or guarantor agrees to pay reasonable attorney1 s fees and collection expense, j. 11 delinquent accounts may bear
interest at the legal rate.
Hollywood Palms agrees to refund overpayments within 48 hours, as long as
eligibility for government or insurance programs has been established, if
8.) MEDICARE: It is understood that patients under Medicare have 100 days a year
of ECF benefits. The first 20 days are paid in full by Medicare. The next 80
days are paid in full with the exception of $5. 00 per day, which patient (or guarantor) agrees to pay at the rate of one month in advance. Paragraph 6 of this
agreement will therefore not be effective until such time as Medicare benefits
are considered exhausted.
(9$/ MEDICAL: Paragraph 6 of this agreement shall not apply except where a patient
has been deemed no longer eligible for Medical. The patient and/or guarantor
agrees to pay whatever liability the Bureau of Public / ssistance decrees.
10. A minimum of 3 days hospitalization shall be effective on all contracts. No
charge will be made for the room if the patient leaves by 11:00 -,.. M.
11. The care and services rendered under this agreement may be terminated upon
one day!s written notice. The patient must be removed on or before expiration
of this period.
12. The undersigned has read the foregoing and understands and agrees to the terms
and conditions herein.
Di:TE: 3~/^ "&'^' PATIENT:
I hereby certify that the Patient: is my
and I hereby agree on my own or his/her behalf to assume and be liable fpr payment
of all your charge s/ as^dascribed above. ,-—/-^. /_ JI .
WITNESS: '" > ' .j - ,- - : ' •/ -; ' GUARANTOR: .A,^AA- •, £^ZLl£—_
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HOLLY JpOD PALMS CONVALESCENT jfOSPITAL ADMISSION t GREEMENT ^ 1. You are authorized to perform all services and treatments as prescribed by Dr. <^' ' .j - ,- - : ' •/ -; ' GUARANTOR: .A,^AA- •, £^ZLl£—_