General Consent Form

This consent applies to Indiana University Health Physicians, its agents, associates, as well as physicians. In each paragraph IU Health
Physicians refers to all IU Health Physicians practices. In each paragraph doctors, independent doctors, residents, and medical students will
be called Physicians.
I agree to let IU Health Physicians, its agents, associates, as well as Physicians give me medical and surgical care. This includes tests, blood
tests, exams, anesthesia, procedures and drugs, which are necessary for the diagnosis and treatment of my medical condition according to the
judgement of my treating Physician.
I agree that IU Health Physicians has not made any claims or statements about results or cures.
I agree that students may help with my health care. My data or body parts including organs, tissue, bone or body fluids may be used for research.
The research may or may not relate to my health care. My data or body parts will be carefully treated so that I cannot be identified, except as
required by law. I agree that I do not own my body parts after removal and that I have no rights to the research products from these parts.
I understand that IU Health Physicians has a commitment to engage in scholarly research and therefore IU Health Physicians may contact me
to determine my interest in participating in research studies.
Infectious Disease Testing: I agree to allow IU Health Physicians to test for infectious diseases including hepatitis and human immunodeficiency virus (HIV), and that

these tests may be ordered by a Physician if one of my caregivers is exposed to my blood or body fluid.
Release of Information: I agree to allow any provider that has given me health care in the past to give my medical records to IU Health Physicians, and that IU Health
Physicians may use my medical records for my health care. I agree that, as necessary for my care, IU Health Physicians may share my medical information with family
members and friends as minimally necessary to make decisions about my care. I agree that as allowed by law, IU Health Physicians may give my medical records to
third-party payors, insurance companies, review agencies, employers, welfare departments, and to third-part data service providers including systems like the Indiana
Health Information Exchange (IHIE) and the Indiana Network for Patient Care (INPC). This may include records about infectious diseases, drug and alcohol abuse
treatment. At anytime, I may change my mind about agreeing to this release of information by giving notice to IU Health Physicians in writing.
HIPAA: I agree that IU Health Physicians has given me the Notice of Privacy Practices.
Pictures: I agree to audio and video recording of my care for IU Health Physicians use only. This includes pictures and recordings used for my medical record, teaching,
and quality monitoring and improvement. I will be asked to sign a separate consent if recordings are used for other purposes.
Personal Belongings: I agree that IU Health Physicians is not liable for loss, theft or damage to my personal belongings.

I know that IU Health Physicians has the right to search any of my things on the premises, including purses and wallets, for the safety and
welfare of its patients and visitors. I know if IU Health Physicians decides an item could be a threat to health or safety, IU Health Physicians may
(1) dispose of it, (2) put it in a safe, or (3) give it to law enforcement.
Payment Responsibility: I know that I am responsible for paying for all the care I receive, and if insurance does not cover all the cost, I must pay the rest. I give IU
Health Physicians the right to release my medical records and information and to receive all payments that I am entitled to under insurance policies. I am responsible for
knowing what insurance coverage I have and for following all insurance policy rules. I know that if I do not pay what I owe IU Health Physicians, they may send the matter
to a collection agency, or attorney and I understand and agree to be responsible for reasonable attorneys fees, court costs, costs of collection and interest.
Duration of Consent: I may revoke this Consent at any time except to the extent IU Health Physicians has already taken action in reliance on it. If I do not revoke it, this
Consent will continue for one year.

I agree that I have read this form carefully and agree that everything in this agreement applies to current and future health care services
provided by IU Health Physicians.

Signature of Patient/Legal Representative

Date

Signature of Guarantor
Date
(if other than the Patient/Legal Representative above)

94962 (0511) Page 1 of 1

Relationship of Legal Representative to the Patient / Patient Name

Adult Witness Signature

Date