FINANCIAL RESPONSIBILITY AND JUDICIAL CLAIMS Financial Responsibility Through this document, I, __________________________________________ acknowledge and accept my responsibility

for the charges related to Professional Hospital Guaynabo, Inc.s services under any of the following circumstances: A. Professional Hospital Guaynabo, Inc. is not a network provider of my insurance. B. Services provided are not covered under my insurance company and/or Medicare. C. I did not fulfill the referral or pre-certification requirements to access the provide services. D. If I decide to stay for additional days and such extension is not covered by my insurance. E. For deductibles and co-payments under the terms of my insurance or Medicare. Judicial Claims By signing this document, I commit and bind myself to the following: A. In the case that I understand that I have suffered physical, emotional, economical or any other injuries as a direct or indirect consequence of the treatment and diagnostic, therapeutic and/or surgical procedures offered by the physicians members of the Medical Staff of the Hospital or by the Hospital and therefore if I propose to initiate a judicial claim, I accept to present this claim, solely and exclusively in the Court of First Instant of the Commonwealth of Puerto Rico, Bayamn Courthouse. B. This commitment of solely and exclusively claim in the State Court includes any claim against the Hospital, its directors, officials, employees, agents, representatives and/or insurance carrier. It also extends to all the physicians that intervene in my care, including their respective spouses and community property. C. In the event that my family and/or significant others propose to claim for damages which I have suffered or damages that they may have suffered as a direct or indirect consequence of the treatment and diagnostic, therapeutic and/or surgical procedures received, this commitment and obligation to claim solely and exclusively in the State Court, I also make extensive to them. Final Acknowledgement My signature in this document represents the following: A. Everything expressed before is correct and true; B. I read or was read to and understood the information provided in this document; C. I reaffirm everything I have recognized and accepted in this document and I do it voluntarily;
INITIALS: _______ Page 1 of 2

D. I recognize that in the event in which any clause or part of this document is declared illegal or null by a Court, said declaration will not lessen the other clauses and its effect will be limited to the declared illegal or null clause. AND TO CONFIRM, I SIGN THIS DOCUMENT. I sign this document on my behalf. In the event that the patient who receives the treatment is a minor or incapable to consent, my signature represents that I am the person entrusted and I have legal capacity to authorize and consent to what is expressed in this document in the name of the patient. ___/___/____ Patients Name: ____________________________________ Date:(month/day/year) Patients Time: ________ AM/PM Signature:________________________________________ If the patient cannot sign due to age minority or is physically or mentally impaired, please fill out the following information. Patients reason for not signing: [ ] Minority [ ] Impairment to consent [ ] Temporary [ ] Permanent Representative(s) Name(s): ______________________________________________ Representative(s) ID #: ___________________________ Representative(s) Signature(s): Representative(s) relation with the patient: [ ] Father [ ] Mother [ ] Son or Daughter [ ] Spouse [ ] Other: Explain: __________________________ Date: ___/___/____
(month/day/year)

Signature: __________________________________________ Signature: __________________________________________ Clerks Name: __________________________________________________ Signature:__________________________________________

Time: ________ AM/PM Date: ___/___/____

(month/day/year)

Time: ________ AM/PM

IMPORTANT NOTE: In the case of impairment due to minority, the consent of both parents (father and mother) is required, except in the case of an emergency certified by the physician. Every person that signs in representation of a patient must provide valid identification to be photocopied and attached to the consent form.

Rev. 05/2009

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