Consent Form

HARTFORD HEALTHCARE CONSENT FOR USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION FOR TREATMENT, PAYMENT, AND HEALTHCARE OPERATIONS 

Hartford HealthCare and HHC as used in this form includes Hartford Hospital, The Hospital of Central Connecticut at NewBritain General and Bradley Memorial, Manchester Memorial Hospital, Midstate Medical Center, Natchaug Hospital,Rushford, The William Backus Hospital, Windham Hospital, Charlotte Hungerford Hospital, St. Vincent’s Medical Center,and Hartford HealthCare Medical Group.

General Consent for Treatment: I consent to and authorize testing, treatment, and outpatient and/or hospital care by Hartford HealthCare (“HHC”) as defined below and its physicians, allied health professionals, employees, residents and other trainees, and/or other authorized agents as they determine is in my best interest. Care this consent covers includes, but is not limited to, physical examination, administration of medications and vaccinations, diagnostic tests, x-rays and other imaging techniques, blood draws, laboratory tests and other tests, treatments or procedures intended to be encompassed within this general consent. I understand that this consent applies for one year from the date of signature. Changes or alterations to this form are not binding on HHC. If I refuse to sign this consent, HHC may provide me with treatment as deemed necessary by the medical team, I will be responsible for charges incurred, and certain health information about me may be disclosed as the law permits.

Acknowledgement of Receipt of Notice of Privacy Practices: I have been offered and/or have received a copy of HHC’s Joint Notice of Privacy Practices that describes how my protected health information may be used and disclosed.

Use and Disclosure of Health Information: I authorize the use and disclosure of my health information for purposes of treatment, payment, and healthcare operations.

Only For Patients Receiving Services Related to Substance Use Disorder (SUD), Behavioral Health, and/or HIV/AIDS: I understand that the above authorization to use and disclose my health information specifically applies to information related to SUD, behavioral health, and HIV/AIDS as applicable.

Audio/Video and Other Recordings. I consent to the use of audiovisual technology, photography and audio, video, and digital recording to be used for my care and treatment and quality improvement purposes. I agree that photos and recordings of me may be used for internal education purposes as HHC deems appropriate. I understand that I will not receive compensation for any such use.

Teaching Facilities: I understand that many HHC locations are teaching facilities and that persons in professional training programs, including but not limited to medicine and nursing, may be involved in my care under appropriate supervision. I may decline care from a trainee by notifying my care team.

Independent Providers: I understand that some providers practicing at HHC are not employees or agents of HHC and are independent contractors. I understand that the use of HHC lab coats, other clothing and identification badges by these independent contractors is not intended to lead anyone to believe that these persons are employees or agents of HHC. I understand that I will be billed separately by these providers for the services they provide. Only if HIV Testing is Medical Necessary or Requested: I understand that Connecticut law does not require a separate consent form to perform HIV testing if the person is informed that they may be tested for HIV and that such testing is voluntary. This general consent authorizes HIV testing if medically necessary or requested, unless I tell my physician/provider that I decline HIV testing.

Billing and Payment: I assign and transfer to HHC and its billing agents all rights of third-party payor benefits for services rendered to me. I authorize any insurance or third-party payments to be made directly to HHC and its billing agents. If HHCHHC Form 577190 R 12-2025 is not a participating provider in my health plan, I accept full financial responsibility for payment of charges incurred. I will be responsible for payment for all non-covered services. Self-pay patients may, upon request, receive a copy of hospital charges related to services they receive. Contact Pre-service Estimates and Collection at 860-696-6380 or [email protected] to request this information.

Communications Via Cellular Phone and E-Mail: If I have provided a cellular phone number and/or e-mail address as a contact, I authorize HHC and its business associates to contact me by cellular phone, text message or e-mail for any reason, including, without limitation, billing, coverage eligibility, automated notifications and appointment reminders. I understand I may be contacted using artificial or pre-recorded voice or auto-dialer technologies. I understand that it is not possible to guarantee that any transfer of information by text or e-mail is 100% timely, complete, accurate, private or secure. Therefore, HHC cannot guarantee the timeliness, completeness, accuracy, privacy or security of my information when sent by text or e-mail. By asking HHC to transmit information to me through text messaging or e-mail, I accept all related risks. I understand that I may opt out of receiving these communications without impacting my ability to receive care.

Personal Valuables in the Hospital: When in the hospital, I am responsible for retaining in my possession all valuables, including but not limited to hearing aids, dentures, and eyeglasses, that are not placed in the hospital safe. If I choose not to place valuables in the hospital safe, HHC will not be liable for any loss or damage to these items.