Hospital Patient Registration Forms

Prior to receiving medical testing/care at Inspira Health you will be required to review and sign several forms to make sure that you understand your rights and responsibilities. Whenever possible, we encourage you to read and understand the forms before your visit. You will be asked to sign the forms during the registration process, so you do not need to print or sign them in advance.

The forms you need to review and sign vary depending on the type of visit and your insurance coverage, which include the following:
  • An outpatient visit, which may take place at a hospital or one of our outpatient Imaging or Urgent Care Centers, where you may have tests, a variety of treatments, or minor surgery
  • Emergency Services/Treatment for medical emergencies, accidents or sudden illness
  • Observation, which is a specific kind of outpatient care. People under observation care remain in a hospital bed while being monitored for a change in their medical condition, usually for less than 24 hours. During that time, a healthcare team decides if the patient needs to be admitted to the hospital or when it’s safe to discharge you
  • An inpatient stay at a hospital, which usually lasts at least two nights, often for surgery, medical treatments, or to stabilize a serious illness or injury.


General Patient Consent Form

This form allows Inspira Health to provide treatment, bill your insurance company and explains our privacy practices under the HIPPA law in addition to your rights as a patient at an Inspira Hospital. All patients seeking elective or emergent services are asked to sign this form. 

English  |  Spanish
 

Important Message from Medicare

This form is given to all inpatient Medicare Beneficiaries who are covered under original Medicare and/or a Medicare Advantage plan. It explains your rights as a patient covered by a Medicare insurance plan. It also provides information on how to appeal your hospital discharge and provides contact information for the Quality Improvement Organization (QIO), assigned by Medicare to review your hospital discharge appeal information. 

English  |  Spanish
 

Medicare Outpatient Observation Notice

This notice is given to Medicare Beneficiaries who are covered under original Medicare and/or a Medicare Advantage plan. It explains that you are an outpatient receiving observation services, not inpatient care, even though you may have been placed on an inpatient unit. Additionally, this notice provides information on how observation services may affect coverage and payment of your care, after you leave the hospital and who you should contact if you have any questions. 

English  |  Spanish
 

A Guide to Outpatient Observation for Non-Medicare Patients

This form is given to commercially insured, Medicaid and self-pay patients who are receiving observation services and are considered an outpatient, rather than an inpatient. This occurs when your doctor has ordered further care and/or treatment to determine if you can be sent home safely or if you require further treatment and must be admitted. Additionally, this form provides information on outpatient observation and frequently asked questions, along with contact information for our Care Coordination team if you have any further questions. 

English  |  Spanish
 

The Advance Beneficiary Notice of Noncoverage (ABN) Form

This is a notice that Medicare providers and suppliers are required to give to patients insured by Original Medicare. The ABN helps a Medicare Fee-For-Service (FFS) beneficiary make an informed decision about items and services Medicare usually covers but may not pay because they are medically unnecessary. Some common reasons Medicare may deny an item or service as not medically reasonable and necessary include care that is:
  • Not indicated for diagnosis or treatment in this case
  • Experimental and investigational or considered “research only”
  • More than the number of services Medicare allows in a specific period for the corresponding diagnosis

Appeals of Utilization Management Determinations

This form outlines the appeal process that can be taken to address situations in which an insurance carrier denies payment for covered services, on the basis that the services are not medically necessary. It describes how Inspira Health can make an appeal on your behalf, of the denied services. It also describes how additional appeals can be done, if you are not satisfied with the initial appeal determination and when and if your appeal can be reviewed by a medical expert under the Department of Banking and Insurance Independent Health Care Appeals Program.

English

Patient Rights

Under Federal and State law, patients have certain rights and must be informed of them when seeking services at health care facilities. Copies of these rights in both English and Spanish are posted throughout our facilities for patients to view and available upon request from registration staff.  

English  |  Spanish

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Copies of Inspira Health’s Notice of Privacy Practices is available in English and Spanish and can be obtained from registration staff, upon request.

English