Important Registration and Billing Information

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Important Registration and BillingInformation

• Schneider Regional Medical Center
• 9048 Sugar Estate
• St. Thomas, VI 00802
• www.srmedicalcenter.org

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Welcome to Schneider Regional Medical Center
Patient Financial Services

• A hospital visit can often be a confusing time.
  Knowing what to expect can really put your mind
  at ease. Thats why weve made it one of our top
  priorities to keep you informed about our
  processes, including our billing procedures.
• We understand that a Hospital Stay or Outpatient
  testing can be a time of concern and anxiety for
  you and your family. Please take this opportunity
  to review some of the processes that you may
  encounter.
• You may be asked to sign in at the reception
  desk. Due to clinical necessity there may be
  times when patients are registered out of order.
  We will assist you with the same urgency as soon
  as possible.
• You are responsible for your own valuables and
  personal items while you are in the hospital.
  Therefore we ask that other than sufficient funds
  to meet your co-payment/deposit requirements, you
  leave your valuables at home.
• We will collect and file your insurance for you.
  Following your visit or stay you will receive
  monthly bills telling you the status of your
  claim. These bills will show what has been
  billed to insurance and will not have a patient
  balance due on them. We encourage payment of
  co-insurance and deductibles up front or you may
  pay them at any time following your time here.

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• Insurance
• Your co-pay, deductible and/or co-insurance are
  due at the time of service. Payments can be made
  by cash, debit cards, personal check, travelers
  check, EFT (Electronic Funds Transfer) or by
  credit card (Visa, MasterCard and American
  Express).
• If we do not have the exact amount due at time of
  service, we will require a deposit. The deposit
  may vary, depending on the particular type of
  service.
• Medicare patients should be prepared to pay their
  inpatient deductible at the time of admission.
• Medicare patients, we are required by Medicare
  to check the diagnosis information that your
  ordering physician has provided with the specific
  test or procedure he/she has ordered when you are
  scheduled for Outpatient services. In some cases,
  Medicare will not pay for a service because they
  feel that the diagnosis does not support the need
  for the test or service requested by your
  physician.
• Please have your insurance card (s) and proof of
  identification readily available.

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• Self-Pay Patients with no insurance agree to pay
  estimated charges prior to treatment. Because we
  realize that health care is expensive, self-pay
  patients are given an automatic 40 discount at
  the time of billing. To obtain the estimated cost
  of your service, please contact Patient Financial
  Service. Any additional charges incurred during
  the visit are the patients responsibility. If
  you are a Self-Pay patient, all payments are
  expected at the time of registration. If you are
  unable to pay, we will require a substantial
  deposit towards your care. The amount of that
  deposit will be directly proportional to the
  class of service you are scheduled to receive.
• Financial Assistance Programs (Federal, State and
  Local) are available). Patients or immediate
  family members should contact a Financial
  Counselor for assistance.
• Pre-Certification Your insurance coverage is a
  contract between you and your insurance company.
  Benefits will vary depending upon the type of
  insurance policy you carry.
• If your insurance requires pre-certification or
  an authorization, we will attempt to obtain them
  for you before your service (s), however,
  remember it is your responsibility to notify your
  insurance company of services that require
  pre-authorization or pre-certification.
• If we have not been able to obtain authorization,
  we may need to cancel or reschedule your service
  (s).
• Pre-Registration We can pre-register any visit
  arranged in advance by a physician. Through
  advance registration, all of the required
  information about you is gathered and placed in
  our files pending your visit. Your service
  representative will discuss financial
  requirements with you at that time.
• If your Physician schedules your service in
  advance, we will attempt to contact you to update
  your demographic information before you arrive.
• Your co-payment, deductible and co-insurance are
  due at the time we are pre-registering you.
  Payment may be made by cash, check, or credit
  card.
• If you would like to schedule any service (s) in
  the future and would like to contact us to
  pre-register, please call 340-776-8311 and
  request Registration Services. Contact us at
  least (3) days prior to your service.
• Registration We offer services without regard to
  religion, race, sex, age, national origin, or
  handicap. Your Service Representative will help
  you complete the appropriate paperwork required
  for your hospital visit.
• Registration will consist of the following
• A Confirmation of your demographic information
• Verification that pre-certification has been
  obtained
• Collection of payments that are due
• Order for the test (s) requested by your
  Physician.

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• Hospital Billing Guide We are providing this
  guide to inform you of what you can expect
  regarding hospital charges for services provided
  to you today, if you have insurance.
• Your hospitalization coverage is a contract
  between you and your commercial insurance
  company. You are responsible for your hospital
  account.
• We will bill your insurance on your behalf as a
  courtesy. Your coverage is a contract between you
  and your insurance company. During the process of
  filing your claim, you will receive a variety of
  letters to keep you informed of the status of
  your account.
• Please be advised that you may obtain
  informational statements until your insurance
  company correctly pays your claim. You may want
  to call your insurance company to see what is
  causing the delay. In many instances, the
  insurance company is waiting for information from
  you or the subscriber.
• After receiving the insurance payment, you will
  receive an Explanation of Benefits from your
  insurance company telling you how the claim was
  processed and informing you of your financial
  responsibility (co-pays, deductibles, and/or
  co-insurance).
• At the time the bill is sent you your insurance
  company, you will receive an itemized statement
  from the hospital which will reflects your
  hospital care, and all the supplies and services
  ordered by your physician. If you need an
  insurance billing form for billing other
  insurance, we can provide you with a copy if you
  contact Patient Financial Services. However, your
  Hospital Bill must first be paid in full.
• Physician Billing You should expect to receive a
  separate bill from the Physicians that may
  assist in caring for you.
• During the course of your stay, your physician
  may request consultations and/or services of
  hospital-based physicians including but not
  limited to, emergency physicians, radiologists,
  pathologists, and anesthesiologists.
• The physicians associated with this hospital may
  be independent, private practicing physicians,
  and may be individually contracted with an
  insurance company. Contact your insurance company
  to verify that both the Hospital and the
  Physician are contracted with your Insurance
  Provider Network. You should expect to receive a
  separate bill from your Physician (s) listed
  below, if applicable
• Emergency Physicians Will be billed via our
  billing system for any services you may have
  received while in the Emergency Department.
• Radiologists Will bill you for reading any
  X-rays that were taken while at the hospital.
• Pathologists Will bill you for any laboratory
  and pathology test (s) they have read while you
  were at the hospital.
• Anesthesiologists will bill you for services
  received during any surgical procedures you may
  have undergone while at the hospital.

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Consent for Admission to Hospital, Medical
Treatment, Release of Records and Responsibility

• Name_____________________________________________
  Date___________________ Time__________________
  ___
• 1. I/We the undersigned, knowing that _________
  is suffering from a condition requiring diagnosis
  and medical or surgical treatment hereby
  voluntarily consent to such diagnostic procedures
  and hospital care by or under the supervision of
  Dr. ______.
• I/We are aware that the practice of medicine or
  surgery is not an exact science and I/We
  acknowledge that no guarantees or assurances have
  been made to me/us with regard to the results
  that may be obtained from treatments or
  examinations in the hospital.
• I/We acknowledge that the Schneider Regional
  Medical Center does not assume responsibility for
  loss or damage to personal property kept in the
  patients room. I/We further acknowledge that
  while the safe is available for the keeping of
  money and valuables of the patient, the Schneider
  Regional Medical Center assumes no responsibility
  for any possessions deposited therein.
• I/We consent to allow students from formal
  education programs for health care professions to
  participate in my/the patients care, under the
  supervision of appropriately licensed an/or
  credentialed members of such disciplines.
• I/We acknowledge that I/We have received a
  written document regarding my/the patients
  rights under Virgin Islands law to make decisions
  about my/the patients medical care, and
  specifically about advance directives, (i.e.
  living wills, etc.) NOTE Included in this
  document is information about the Schneider
  Regional Medical Centers policies as regards
  advance directives.
• I/We consent to the release of information to
  friends, relatives and others who may inquire,
  information to be released includes patients
  name, admission or discharge, medical condition
  in general terms, hospital room and hospital
  phone number.
• If applicable, I/We authorize the Schneider
  Regional Medical Centers pathologist to use his
  discretion in the disposal of any specimen or
  tissue obtained from the patient during the
  course of diagnosis or treatment.
• If applicable, I/We consent to the administration
  of such anesthetics as are necessary and applied
  by or under the direction of the medical
  anesthesia department. Note exceptions, if
  any____________________.
• I/We understand that some insurance companies
  require authorization for inpatient admissions or
  specific procedures, and that maximum
  reimbursement may not be received if
  authorization is required and I/We do not have
  it, I/We assume the responsibility of obtaining
  such authorization if necessary and understand
  that Schneider Regional Medical Center cannot
  obtain such authorization for me/us.
• I/We authorize Schneider Regional Medical Center
  and/or any doctor involved with my/the patients
  care including those performing diagnostic
  radiology (x-ray) services, anesthesiology
  services, pathology services, emergency services,
  or other similar specialty services to release
  any information from my/the patients medical
  record as requested by the patients insurance
  company for payment of the hospitals or
  physicians accounts.
• I/We assign all insurance benefits due to or
  received by me/us to Schneider Regional Medical
  Center, and/or the doctors involved with my/the
  patients care including those performing
  Radiology, Anesthesiology, Pathology or Emergency
  Services or other similar specialty services as
  total or partial payment for services provided.
  I/We understand that this assignment may not
  constitute full payment of my/the patients bill,
  and does not relieve me/us from liability for the
  unpaid balance. If insurance benefits to which
  I/the patient (s) are entitled are paid directly
  to me/us, such benefits will upon be immediately
  delivered to Schneider Regional Medical Center
  (or the appropriate physician) by me/us until the
  full amount of all charges incurred are paid in
  full.
• I/We agree to pay directly to Schneider Regional
  Medical Center and/or such doctors the charges
  incurred for services rendered/received, at their
  established rates. I/We will pay all attorneys
  fees and court costs incurred by Schneider
  Regional Medical Center or such doctors in
  collecting any unpaid balances for services I/the
  patient received.
• DO NOT SIGN THIS FORM UNTIL YOU HAVE READ IT AND
  UNDERSTAND ITS CONTENTS
• __________________________________ _______________
  ____________________________
• (WITNESS) (SIGNATURE OF PATIENT)

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Medicare Information for our Patients

• Medicare fraud steals millions of dollars every
  year from the Medicare program. Beneficiaries pay
  for it with higher premiums. Fraud occurs when
  someone knowingly deceives or misrepresents
  themselves in a way that could result in
  unauthorized payments being made. Fraud schemes
  may be carried out by individuals, institutions,
  or groups of individuals.
• Medicare fraud includes, but is not limited to
• Billing for more expensive services at a higher
  service fee than was actually provided.
• Falsifying certificates of medical necessity,
  plans of treatment, and medical records to
  justify payment.
• Billing for services not furnished.
• Soliciting, offering, or receiving a kickback.
• Billing separately for services that should be
  included in a single service fee.
• Misrepresenting the diagnosis to justify payment.
• Medicare is improving its capability to crack
  down on those who take advantage of this program.
  We are using four methods to fight fraud and
  abuse prevention, early detection, coordination
  with other government agencies, and prosecution
  of wrongdoers.
• We need your help to stop Medicare fraud and
  abuse. You can help protect Medicare and yourself
  by reporting all suspected instances of fraud and
  abuse. When you receive payment notices from
  Medicare, review them for errors. Make sure
  Medicare did not pay for services, medical
  supplies, and/or equipment that you did not
  receive.
• Reporting Medicare Fraud and Abuse
• If you have a questionable charge on your bill,
  call the provider, your Fiscal Intermediary (for
  Part A bills) or your Medicare carrier (for Part
  B bills). If you believe that a health care
  provider may be cheating or abusing the Medicare
  program, call the Medicare carrier or
  intermediary that sent you the payment notice.
  Their name, address, and telephone number appear
  on the payment notice. After you call the
  Medicare carrier or Fiscal Intermediary, you may
  also call the Inspector Generals hotline at
  1-800-HHS-TIPS (1-800-447-8477), or TTY for
  hearing and speech impaired 1-800-377-4950.
• From publication No. HCFA 10111

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To Our PatientsIn accordance with the
Admissions/Registration Policies and Procedures
of the Schneider Regional Medical Center, it is
our obligation to inform you and your family
members of the following policies involving

• Patients Rights and Responsibilities
• Patient Advocacy Information
• Copy received Patient or Legal Guardian__________
  _______________ Date______________
• Admitted by _____________________________________
  ___________ Date______________

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Patient Rights Responsibilities
The Schneider Regional Medical Center DBA Roy
Lester Schneider Hospital, Myrah Keating Smith
Community Health Center and Charlotte Kimmelman
Cancer Institute are dedicated to serving the
whole patient regardless of race, creed, social
or economic status, believing that the rights and
dignity of every patient must be protected and
promoted with care. The hospital and health
center endeavor to protect the patients rights
to privacy and keep patient records and
communications confidential, in accordance with
professional ethics and the law. The Schneider
Regional Medical Center organizations are
committed to safeguarding the right of each
patient to information about and participation in
decisions regarding medical care, and to
promoting respect and dignity for all
individuals. In the case of a minor, the
following rights and responsibilities are
afforded the patients parent or guardian.

• You Have the Right To
• Considerate and respectful care, which optimizes
  your comfort and dignity throughout your
  treatment.
• Access to treatment regardless of gender, age,
  disability, ethnicity, religion, or source of
  payment. This includes the right to supportive
  social and pastoral services that respect your
  personal value and belief system.
• Expect that every attempt will be made to provide
  an interpreter, if your spoken language is not
  English, or if you are deaf or hearing impaired.
• Receive aggressive, timely and appropriate pain
  management when indicated.
• Participate in the consideration of ethical
  issues that arise in the course of your care.
• Personal privacy and confidentiality. Be free
  from all forms of abuse or harassment, including
  the right to access protective services, if
  needed.
• Receive information about, and an explanation of,
  your hospital bill.
• Request a copy of your completed medical record
  and obtain the copy within a reasonable
  timeframe.
• To know if this hospital/health center has
  relationships with outside parties that may
  influence your treatment and care. These
  relationships may be with educational
  institutions, other health care providers, or
  insurers.

• Act in partnership with your health care
  providers to make decisions regarding your care.
• Advance Directives you have the right to
  formulate an Advance Directive or to appoint a
  surrogate to make health care decisions on your
  behalf.
• Informed consent, including the right to have
  treatment options explained so that you
  understand the benefits, risks, and treatment
  choices.
• Refuse treatment to the extent permitted by
  ethics and law, and to be informed of the medical
  consequences of your action.
• To obtain pertinent information information as to
  any relationship of this hospital/health center
  and other health care institutions which may
  affect your care.
• It Is Your Responsibility To
• Be Part of Your Care
• Be as accurate and complete as possible when
  providing medical history and treatment
  information.
• Inform your health care provider if you have any
  questions regarding care and treatment.
• Partner with the health care providers to develop
  an appropriate plan of care.

• Be treated by skilled, compassionate, caring
  physicians, nurses, and hospital staff.
• Know the names and roles of the providers caring
  for you.
• Be well informed about your illness, possible
  treatments, likely and unanticipated outcomes,
  and to discuss this information with your
  healthcare provider.
• Be advised if the hospital/health center proposes
  to engage in research projects affecting your
  care or treatment, and the right to refuse to
  participate in such studies without compromising
  the quality of care you receive.
• Receive a high standard of patient care and
  safety while in the hospital setting. The
  hospital/health center, your doctor, and health
  care professionals will protect your safety and
  security as much as possible.
• Be free from chemical or physical restraint
  except as authorized by a physician or in an
  emergency when necessary to protect you or others
  from injury.
• Receive appropriate discharge teaching and
  instruction for self-care, including awareness of
  community resources available to provide
  supportive care.

• Participate in the designated plan of care.
• Notify your health care providers if the
  designated plan of care cannot be followed.
• Provide a copy of your Advance Directive" to the
  hospital/health center.
• Notify your health care providers or the Patient
  Representative at x2302/Administrator MKSCHC
  693-8900 if you are not satisfied with the care
  you received.
• Respect and Consider the Rights of Others
• Be considerate of the rights of other patients
  and their families.
• Be considerate of the physicians and
  hospital/health center personnel.
• Provide the hospital/health center with accurate
  and timely information concerning the sources of
  payment and ability to meet financial obligations
  associated with care.
• Ensuring a Safe Hospital Stay
• The single most important way you, as a patient,
  can help to prevent errors is to be an active
  member of your health care team. Speak up! if you
  have any questions or concerns.

• Discuss your concerns with your nurse, physician,
  or if you have a commendation or complaint about
  the quality of your care, you may call the
  Hospital Operator to page the Patient
  Representative or after hours, page the Nursing
  Supervisor. At Myrah Keating, Contact the
  Administrator.

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Patient Relations

• The Patient Relations Department at Schneider
  Regional Medical Center is here to serve as the
  Patients Advocate. Our mission is to address
  questions or concerns you or your family members
  may have about care, hospital policies and
  procedures, or the quality of hospital services.
  Patient Relations representatives are also happy
  to receive compliments, suggestions, and other
  recommendations that might improve the services
  provided by this facility.
• Compliments if you would like to thank a special
  staff member or volunteer who made your hospital
  stay especially comfortable, Patient Relations
  can assist you. Our team members are energized by
  receiving suggestions or recommendations for
  future improvements. A word of thanks from the
  patients we care for helps to lift our spirits
  and morale! We encourage you to send cards,
  emails, or any other correspondence about the
  service you may have received.
• Grievances and Concerns If you have a complaint,
  you may register it verbally or in writing with a
  representative. Your particular concern will be
  investigated and a resolution will be provided as
  soon as possible.
• As a Medicare patient, you also have the right to
  have your grievance regarding quality of care or
  premature discharge referred to and independently
  reviewed by the Virgin Islands Medical Institute
  Peer Review Organization (VIMI PRO). If you would
  prefer to contact the VIMI PRO directly, you may
  do so at 340.712.2400 or 712.2449. An independent
  review of your case will be conducted. This
  procedure can be initiated at your request, via
  Patient Relations and the Office of the Medical
  Director.
• If you have a complaint regarding a HIPAA privacy
  violation, you may direct it to The Director of
  Privacy, Compliance and Health Information
  Management, Ms. Patricia Lake-Blyden, RHIA at
• Extension 2253
• 9048 Sugar Estate
• St. Thomas, VI 00802
• In the even that you or your family would like to
  file your grievance outside of the Hospitals
  internal grievance process, you may forward your
  written grievance to
• Commissioner of Health, or Designee
• USVI Department of Health
• 9048 Sugar Estate, 5th Floor
• St. Thomas, VI 00802
• 340.774.0117
• When sharing your compliments and concerns with
  our department, please be sure to include your
  name, date of stay, the unit, the nature of the
  issue, the names of any individuals whom you feel
  are important to the issue at hand, and how you
  would like to see the matter resolved.
• Our hospital also conducts Patient Satisfaction
  Surveys through a nationally recognized survey
  research consultant firm The Jackson
  Organization. After you have completed your
  service and have been discharged, you may receive
  a call from the surveyors. Please feel free to
  share your responses with them. They compile the
  important information that you share with them,
  and submit it to our Hospitals Administration so
  that we can continue to improve our services and
  processes.
• Patient Relations Contact Information
• Christine deJongh-Lewis, MPH

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Medicare Appeals and Grievances (Complaints)

• In the Original Medicare Plan If you are
  dissatisfied, you have a right to appeal any
  decision concerning your Medicare covered
  services in the Original Medicare Plan. You can
  file an appeal if you believe Medicare did not
  pay enough for services or should have paid for
  health care services you received. Your appeal
  rights will be detailed on the back of the
  Medicare Summary Notice (MSN) or Explanation of
  Medicare Benefits (EOMB) that is mailed to you.
• If you believe you are being discharged too soon
  from a hospital, you have a right to immediate
  review by the Peer Review Organization. Peer
  Review Organizations (PROs) are groups of
  practicing doctors and other health care
  professionals paid by the federal government to
  monitor the care given to Medicare patients. They
  are responsible for reviewing beneficiary
  complaints about the quality of care provided by
  inpatient hospitals, hospital outpatient
  departments and hospital emergency rooms skilled
  nursing facilities home health agencies
  Medicare Managed Care Plans and ambulatory
  surgical centers. You can stay in the hospital at
  no charge and cannot be discharged before the PRO
  makes a decision.

• In Other Medicare Health Plans You have a right
  to appeal decisions concerning your Medicare
  benefits in the other Medicare health plans. If
  you have any concerns or problems with your plan,
  you also have a right to file a grievance
  (complaint). You have these rights regardless of
  the type of plan in which you are enrolled. To
  participate in Medicare, each health plan must
  have an appeal and grievance process for its
  members. See the health plans membership
  materials or contact your health plan for details
  about your rights and how to file a Medicare
  appeal and complaint.
• You may file an appeal if your health plan denies
  a service or terminates or refuses to pay for
  services that you believe should be covered. You
  may be eligible for a fast decision (within 72
  hours) if you believe that your health or ability
  to function could be seriously harmed by waiting
  the amount of time needed for a standard
  decision. Your health plan must provide you with
  written instructions on how to appeal. The first
  step is to contact your plan.
• After you file an appeal, the health pan reviews
  its original decision to deny you coverage. Then
  if your health plan does not decide in your
  favor, the appeal automatically goes to an
  independent reviewer that contracts with
  Medicare.
• If you believe you are being discharged too soon
  from a hospital, you have a right to immediate
  review by the Peer Review Organization (PRO) in
  your State. During the immediate PRO review, you
  may be able to stay in the hospital at no charge
  and the hospital cannot discharge you before the
  PRO reaches a decision.
• From publication No. HCFA 10119

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HIPAA Notice of Privacy Practices

• Your Privacy Rights
• The following is a summary of your rights with
  respect to your protected health information
  (Please be aware that the Schneider Regional
  Medical Center can deny your requests in certain
  circumstances.)
• You may request a restriction on uses and
  disclosures of your health information.
• You may request that our communications to you be
  confidential.
• You may request to inspect and copy your
  protected health information ( we may charge a
  fee for copying your record.)
• You may request an accounting of disclosures of
  your health information.
• You may request an amendment of your protected
  health information.
• You have the right to receive a copy of the
  complete Notice of Privacy Practices.
• You should also know that if you have greater
  protections under a specific U.S. Virgin Island
  statute or regulations, those protections will
  continue to apply to you.
• Complaints or Additional Information
• You may file a complaint to us or to the
  Secretary of Health and Human Services if you
  believe that we have violated your privacy
  rights. You may also request additional
  information about this Notice of Privacy
  Practices.
• Write to
• Roy Lester Schneider Hospital
• Attention Patricia Lake-Blyden, Compliance and
  Privacy Officer
• 9048 Sugar Estate
• St. Thomas, VI 00802
• Other Complaint Filing Information

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HIPAA Notice of Privacy PracticesHospital/Health
Center Responsibilities

• Schneider Regional Medical Center is required by
  law to maintain the privacy of your protected
  health information and to give you notice of our
  duties and privacy practices. This Notice
  describes how we may use and disclose your
  individually identifiable health information.
  This Notice also describes your rights to access
  and control your health information.
• We must follow the terms of this Notice. We
  reserve the right to change this Notice
  consistent with the law. If we change this
  Notice, we will post a revised Notice and will
  make paper copies of the complete Notice
  available upon request. The terms of this Notice
  of Privacy Practices are consistent with the
  federal HIPAA Privacy Regulations. Any term
  not defined in this Notice have the same meaning
  as it has in the HIPAA Privacy Regulations.
• Uses and Disclosures of Your Protected Health
  Information
• We are legally permitted, without further notice
  to or consent from you, to use and / or disclose
  your protected health information in the
  following circumstances.
• For treatment, payment or healthcare operations
  or to others involved in your care
• To other covered entities or for public health
  activities
• To the Food and Drug Administration (FDA)
• For Workers Compensation or in other legal
  proceedings
• To Coroners, Medical Examiners, Funeral
  Directors, Organ Donation Agencies
• For approved research
• For disaster relief programs or health oversight
  activities
• To business associates
• For abuse or neglect reporting or as otherwise
  required by law
• Health-related benefit information
• To law enforcement personnel or for inmates of
  prison facilities
• Military activity and national security,
  protective services
• Prevention of a serious threat to health or
  safety
• Limited information for a facility directory and
  to clergy
• We are required by law to disclose health
  information to the following people

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Advance DirectivesLiving Will and Designation of
Health Care Surrogate

• As a patient, you have the right to formulate
  Advance Directives and to make decisions
  concerning your medical care, including the right
  to accept or refuse medical/surgical treatment.
  The Roy Lester Schneider Hospital is committed to
  helping facilitate your expressed wishes
  concerning your health care. Our hospital will
  honor your directive within the limits of the law
  and our mission, vision, and values. You will
  receive the same medical treatment from Roy
  Lester Schneider Hospital whether or not you have
  signed an Advance Directive.
• Advance Directives are legal documents that you
  may complete to help ensure that your wishes are
  carried out when you are unable to speak for
  yourself. These documents indicate your choices
  regarding health care decisions, including, but
  not limited to, life-prolonging procedures and
  the designation of someone to make health care
  decisions in the event you would be unable to
  make decisions for yourself. Advance Directives
  are commonly known as the Living Will and
  Designation of a Health Care Surrogate.
• The Living Will is an Advance Directive Document
  that allows you to indicate your choices
  regarding the use of life-prolonging procedures.

• According to law, when two physicians certify
  that you have either a terminal condition,
  end-stage condition or are in a persistent
  vegetative state, your Living Will can be
  honored. Your may also designate a person to
  make health care decisions for you if you become
  mentally or physically unable to do so yourself.
  This may be done by completing a Designation of
  Health Care Surrogate document. It is very
  important that your wishes expressed in these
  documents be discussed with your physician and
  family / significant other.
• We would like to request that each time you come
  to the hospital to be admitted as an inpatient
  that you bring a copy of your most recently
  completed Advance Directives. During your
  admittance, as an adult inpatient, you will be
  asked if you have completed an Advance Directive.
  Your response will be documented in your medical
  record. If you have already signed an Advance
  Directive document and didnt bring it to the
  hospital, you will be asked to complete another.
• You may request Advance Directive forms from the
  Admitting Department or designated employee, or
  your nurse.

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