Today's Date 

Date of Birth




Next of Kin


Person to Notify

(Note: we will only call this number for medical needs)

Primary Policy Holder

Date of Birth

Secondary Policy Holder

Date of Birth

Is today's visit due to:

Date of Accident/Symptoms Began


Surgery/Medical Procedures & Other Diagnostic Testing

I understand the Novel Coronavirus (COVID-19) is a relatively new virus and the medical community is still trying to understand how it spreads, develop effective treatments and/or vaccines, and otherwise understand the risks associated with performing surgeries/medical procedures* during the COVID-19 outbreak. I also understand that the Facility has implemented reasonable safeguards to help reduce the spread of COVID-19, but safeguards may not be 100% effective against this extremely contagious virus.

I acknowledge that my physician has explained to me the relative risks Involved with my surgery/medical procedure testing related to Novel Coronavirus (COVID-19), including the possible transmission of COVID-19 during my surgery/medical procedure, delaying my surgery/medical procedure until after COVID-19 Is less prevalent, and possible complications that may arise related to my surgery/medical procedure and transmission of COVID-19.

I understand that COVID-19 testing is not 100% accurate; the test may fail to detect the virus and I could still have the virus even If I do not have any symptoms. I also understand that If] do have the COVID-19 infection this may lead to a higher complication rate for my surgery/medical procedures or even death. If I am exposed to COVID-19 before, during, or after my surgery/medical procedure, I acknowledge that It may result in one or more of the following: (1) a positive COVID-19 diagnosis; (2) isolation, additional tests, transfer to a higher level of care and hospitalization (Including possible admission to an Intensive care unit (ICU), intubation and ventilator support); or (3) death.

By signing below, I certify that I accept the risks associated with proceeding with my surgery/medical procedure during the COVID-19 outbreak and I do not want to delay my surgery/medical procedure to a later date.

* “Surgerles/medical procedures” include other diagnostic testing and medical care performed in the facility.

Today's Date  
Today's Date 


I acknowledge and agree that Methodist McKinney Hospital and any affiliates or vendor thereof, including collection or billing companies, may contact me by email, telephone or text message to any telephonic number or email address I have provided to you, and any other telephone number associated with my account, including wireless or mobile telephone numbers. I further agree that you may use any method of contact to these numbers, such as an Automated Telephone Dialing System (ATDS) or prerecorded message. I also agree that I will notify Methodist McKinney Hospital if I have given up ownership or control of any such telephone number.

Today's Date 

Patient's Approval for Appeals

To whom it may concern:

I authorize Methodist McKinney hospital to submit an Appeal on my behalf, to my insurance company, in order to get the claim(s) paid that were billed form the services performed at their facility.
Today's Date 

Patient Notification of Admission Acknowledgement

Dear Patient:

Federal law requires that we ask you whether or not you wish to have a family member or representative notified of your admission. We are also required to ask if you wish to have your personal physician notified. Please select from the options below and provide the necessary information.

Thank You


Signature of Patient / Surrogate Decision Maker
Today's Date 

Consent to Medical and Surgical Procedures: The undersigned consent to the procedures which may be performed during this hospitalization or on an outpatient basis, including emergency treatment or services, which may include but are not limited to: laboratory procedures, x-ray examinations, medical or surgical treatment or procedures, anesthesia, or hospital services rendered to the patient under the general and special instructions of the patient's physician or surgeon. A separate consent for specific treatment or services may need to be signed in addition to this form as required by hospital policy.

Nursing Care: This hospital provides only general duty nursing care unless, upon orders of the patient's physician, the patient needs more intensive nursing care. If the patient's condition. requires the service of a special duty nurse, it is agreed that such an arrangement will be made by the patient or his/her legal representative. The hospital shall In no way be responsible for failure to provide the same and is hereby released from any and all liability arising from the fact that said patient Is not provided with such additional care.

Legal Relationship Between Hospital and Physician: All physicians and surgeons furnishing services to the patient, including the radiologist, pathologist, anesthesiologist, and the like, are indepeаdont contractors with the patient and are not employees or agents of the hospital. The patient is under the care and supervision of his/her attending physician and it is the responsibility of the hospital and its nursing staff to carry out the instructions of such physician. It is the responsibility of the patient's physician or surgeon to obtain the patient's Informed consent, when required, for medical or surgical treatment, special diagnostic or therapeutic procedures, or hospital services rendered to the patient under the general and special instructions of the physician.

Release of Information: I agree that the Hospital may disclose my 'protected health information" (PHI) In compliance with HIPAA Privacy Provisions which may include my medical records to any third-party payers, including but not limited to health insurers, health care service plans, state and federal agencies, workers compensation carriers, manufacturers required by FDA to track medical devices, or my employer. This includes appropriate release of and disclosure of my medical records in compliance with Privacy Provisions to my physician and other healthcare providers when necessary for my treatment and general health. While I am in the hospital for treatment and care, the hospital has permission to disclose pertinent Information family members, friends, or designated caregivers who may be present with me. I understand that if I am not present in the facility, my personal health information will not be disclosed unless I agree to disclose. Special permission is needed to release this information if the patient is treated for alcohol or drug abuse.

Advanced Directives: I understand that advance directives may include wing wills or other probate arrangements, durable power of attorney, or appointment of a “healthcare surrogate".

Please read and initial applicable statements and select the words {DO or DO NOT}

1. I DO have an executed Advanced Directive and have been requested to supply a copy to the hospital.
2. I DO NOT have an executed Advance Directive. The hospital has offered me Information on Advanced Directives which I  wish to receive.
3. I DO have an executed Durable Power of Attorney for healthcare decisions.

4. I DO NOT have an executed Durable Power of Attorney for healthcare decisions. The hospital has offered me information on Durable Power of Healthcare which I   wish to receive.

Patient Visitation Rights: Methodist McKinney Hospital encourages and facilitates visitation in a manner that promotes healing, balances the needs of all patients and visitors, and creates a safe and secure environment.
  Personal Valuables: The hospital shall not be liable for the loss or damage to any money, jewelry documents, furs, fur coats, and fur garments or other articles of unusual value and small size. The hospital shall not be liable for loss or damage to any other personal property. The patient agrees to send valuables home with family members or in a rare situation or emergency the patient will notify their purse that they need their valuables deposited with the hospital for safekeeping at which time valuables will be itemized, patient will sign valuable receipt along with two hospital employees.

Financial Agreement: The undersigned agrees, whether he/she signs as agent or as patient, that in consideration of the services to be rendered to the patient, he/she hereby individually obligates himself/herself to pay the account of the hospital in accordance with the regular rates and terms of the hospital. Should the account be referred to an attorney or collection agency for collection, the undersigned shall pay actual attorneys' fees and collection expenses. All delinquent accounts shall bear interest at the legal rate. I agree to pay the hospital in accordance with its regular rates and terms. TERMS: Net 30 days from date of invoice unless otherwise indicated on a promissory note. Should collection become necessary, the responsible party agrees to pay any additional collection fees, and all legal fees of collection without suit, including attorney fees, court costs, and filing fees.

Assignment of Insurance Benefits: I authorize direct payment to the Hospital of any insurance benefit. I understand that I am responsible for any charges not paid by my insurer and I agree to pay any unpaid balances on my account no more than 90 days after the date of service.

Disclosure of Ownership: The physician who refers you to our Hospital may have an ownership interest in this hospital. You are free to choose another hospital in which to receive services.

Medicare Certification, Authorization to Release Information, and Payment Request: I certify that the information given by me in applying for payment under Title XVII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. HIPAA Privacy Notice: I acknowledge that I have received the Hospital HIPAA Privacy Notice and have had the opportunity to review its content. 
Patient Bill of Rights: I acknowledge that I have received the Patient Bill of Rights.I certify that I have read this document and I am the patient or I am duly authorized to execute it and accept its terms.

Assignment of Insurance Benefits: The undersigned authorizes, whether he/she signs as agent or as patient, direct payment to the hospital of any insurance benefits otherwise payable to or on behalf of the patient for this hospitalization or for these outpatient services, including emergency services if rendered, at a rate not to exceed the hospital's actual charges. It is agreed that payment to the hospital, pursuant to this authorization by an insurance company shall discharge said insurance company of any and all obligations under a policy to the extent of such payment. It is understood by the undersigned that he/she is financially responsible for charges not paid pursuant to this assignment.

Healthcare Service Plan Obligation: This hospital maintains a list of healthcare service plans with which it contracts. A list of such plans is available upon request from the financial office. The hospital has no contract, express or implied, with any plan that does not appear on the list. The undersigned agrees that he/she is individually obligated to pay the full charges of all services rendered to him/her by the hospital if he/she belongs to a plan which does not appear on the above-mentioned list. The undersigned certifies that he/she has read the foregoing, received a copy thereof, and is the patient, the patient's legal representative, or is duly authorized by the patient as the patient's general agent to execute the above and accept its terms.

Today's Date 


Financial Responsibility Agreement by Person Other than the Patient or the Patient's Legal Representative: I agree to accept financial responsibility for services rendered to the patient and to accept the terms of the Financial Agreement, Assignment of Insurance Benefits, Healthcare Service Plan Obligation provisions above.

Disclosure of Ownership Notice

Dear Patient:

We are required by Federal law to notify you that this Hospital meets the Federal definition of a “physician-owned hospital” as specified in 42 C.F.R. § 482.13(b)(2). The physician who referred you to our Hospital, the Methodist McKinney Hospital, may have a financial interest in this Hospital. You are free to choose another facility in which to receive services.

Methodist McKinney Hospital Physician Investors:
Michael D. Adams, M.D.
Jean Louis Benae, M.D.
Stephanie Berg, M.D.
Lee Alan Brock, M.D.
Jeffrey L. Burchard, M.D.
Richard Burg, M.D.
​​​Craig A. Chambers, M.D.
Jacob Chun, M.D.
Chris Cottrell, M.D.
Jason Davis, M.D.
Sarang N. Desai, D.O.
Troy C. Diehl, D.O.
Steve Duffy, M.D.
Rhonda D. Hopkins, MD, PA
William B. Humeniuk, M.D.
Kevin T. Joyner, M.D.
Justin Kane, M.D.
Neal C. Lawrence, M.D.
David Liao, M.D.
Jeffrey Lue, M.D.
Daniel R. Maurer, D.O.
Doug Maxey, M.D.
Sacheen H. Mehta, M.D.
Wesley Merritt, M.D.
 Chris R. Miller, M.D.
Andrew Minigutti, M.D.
Steven B. Morgan, M.D.
Ripul R. Panchal, D.O.
Manju Pandey, M.D.
H. Lynn Rodgers, Jr., M.D.
Timothy L. Sandmann, M.D.
Brian J. Snow, M.D.
Ann H. Snyder, MD, PA
Jared D. Stringer, M.D.
Jon Thompson, M.D.
Charles Toulson, M.D.

Should you have any questions or concerns, please do not hesitate to contact me at 972-569-2700.

Sincerely, Joe Minissale, President
Methodist McKinney Hospital

All hospital personnel, medical staff members and contracted agency personnel performing patient care activities shall observe these patients' rights.


The care a patient receives depends partially on the patient himself. Therefore, in addition to these rights, a patient has certain responsibilities as well. These responsibilities should be presented to the patient in the spirit of mutual trust and respect:
  The patient is responsible for following hospital policies and procedures.



1. For your treatment. We may share your protected health information with other treatment providers. For example, if you have a heart condition we may use your information to contact a specialist and may send your information to that specialist. We may send your information to other treatment providers as necessary.

2. For Payment. We may share your protected health information with anyone who may pay for your treatment. For example, we may need to obtain a pre-authorization for treatment or send your health information to an insurance company so it may pay for treatment. However, if you pay out of pocket for your treatment and make a specific request that we not send information to your insurance company for that treatment we will not send that information to your insurer except under certain circumstances. We may also contact you regarding payment of your bill.

3. For Our Healthcare Operations. We may use and disclose your protected health information when it is necessary for us to function as a business or provide services. When we contract with other businesses to do specific tasks or services for us, we may share your protected health information related to those tasks or services, (for example, assisting with billing or insurance claims). When we do this, the business agrees in the contract to protect your health information and use and disclose such health information only to the extent necessary to complete the assigned tasks or as we would use it in the Hospital. These businesses are called "Business Associates" and our contract for their services is called a "Business Associate Agreement" Another example is our internal review of your protected health information as part of our quality process, patient safety review and staff performance.

4. For Appointment Reminders. We may use your protected health information to remind you of appointments, including leaving a voicemail message.

5. For Surveys. We may use and disclose your protected health information to contact you to assess your satisfaction with our services.

6. For providing your information on treatment alternatives or other services. We may use and disclose protected health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you. We may also use and disclose protected health information to tell you about health-related benefits or services that may be of interest to you. In some cases, the Hospital may receive payment for these activities. We will give you the opportunity to let us know if you no longer wish to receive this type of information.

7. To discuss your treatment with other people who are involved with your care (and for our hospital directory if appropriate). We may disclose your health information to a friend or family member who is involved in your care. We may also disclose your health information to an organization assisting in a disaster relief effort so that your family can be notified about your condition, status, and location. (Unless you inform us that you do not want any information released, we may tell individuals who ask your location in the hospital and provide a general statement of your condition]

8. Research. Under certain circumstances, we may use and disclose your protected health information for medical research. All research projects, however, are subject to a special approval process. Before we use or disclose your health information for research, the project will have been approved.

9. As Required By Law. We will disclose your protected health information when the law requires us to do so.

10. To Avert a Serious Threat to Health or Safety. We may use and disclose your protected health information when necessary to prevent a serious threat to your health and safety or the health and safety of another person.

11. Organ and Tissue Donation. We may use or disclose your protected health information to an organ donation bank or to other organizations that handle organ procurement to assist with argan or tissue donation and transplantation

12. Military and Veterans. The protected health information of members of the United States Armed Forces members of a foreign military authority may be disclosed as required by military command authorities.

13. Employers. We may disclose your protected health information to your employer if we provide you with health care services at your employer's request and the services are related to an evaluation for medical surveillance of the workplace or to evaluate whether you have a work-related illness or injury. We will tell you when we make this type of disclosure. 1

4. Workers' Compensation. We may release your protected health information for workers' compensation or similar programs providing you benefits for work-related injuries or illness.

15. Public Health Risks. We may disclose your protected health information for public health activities which include the prevention or control of disease, injury, or disability, to report births and deaths; to report child abuse or neglect to report reactions to medications or problems with products to notify people of recalls of devices or products, to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition or to notify the appropriate government authority if we believe you have been the victim of abuse, neglect or domestic violence. If you agree, we can provide immunization information to schools.

16. Health Oversight Activities. We may disclose your protected health information to a health oversight agency for activities authorized by law. These activities are necessary for the government to monitor the health care system government programs and civil rights laws.

17. Legal Proceedings. We may disclose your protected health information when we receive a court or administrative order. We may also disclose your protected health information if we get a subpoena or another type of discovery request. If there is no court order or judicial subpoena, the attorneys must make an effort to tell you about the request for your protected health information.

18. Law Enforcement. When a law enforcement official requests your protected health information, it may be disclosed in response to a court order, subpoena, warrant summons, or similar process. It may also be disclosed to help law enforcement identify or locate a suspect, fugitive, material witness, or missing person. We may also disclose protected health information about the victim of a crime: about a death we believe may be the result of criminal conduct about criminal conduct on the premises; ar in an emergency to report a crime, the location of the crime, victims of the crime, or to identify the person who committed the crime.

19. Coroners, Medical Examiners, and Funeral Directors. We may disclose your protected health information to a coroner, medical examiner, or funeral director.

20. National Security and Intelligence Activities. When authorized by law. we may disclose your protected health information to federal officials for intelligence, counterintelligence, and other national security activities.

21. Protective Services for the President and Others. We may disclose your protected health information to certain federal officials so they may provide protection to the President other persons, or foreign heads of state, or to conduct special investigations.

22. Inmates or Persons in Custody. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release your protected health information to the correctional institution or a law enforcement official when it is necessary for the institution to provide you with health care, when it is necessary to protect your health and safety or the health and safety of others, or when it is necessary for the safety and security of the correctional institution.

23. Fundraising. We may send you information as part of our fundraising activities. As you review our fundraising materials, you will see information giving you the opportunity to "opt-out" of (meaning "choose not to participate in") receiving fundraising materials in the future. If you notify us that you wish to opt-out as provided in the materials sent to you with that mailing, we will not send you fundraising information or mailings in the future.


1. Most uses and disclosures of psychotherapy notes require your authorization. Psychotherapy notes are a particular type of protected health information. Mental health records generally are not considered psychotherapy notes.
2. Your authorization is necessary if we sell your protected health information.

3. If we use your protected health information to communicate about a third party's product or service that encourages you to use that product or service, and, if we are paid for that communication we will get your authorization. These communications can take various forms like mailings, email communications, and telephone communications. However we will not need your authorization to provide you information face-to-face (example, in the Hospital); to send bills or request payment for services rendered: to communicate with you about your treatment to provide you with prescription drug refill reminders; to communicate with you about health care issues generally, or to communicate with you about Government programs.

4. We will get your authorization if we use your health information for marketing.

5. We will sometimes notify you about our health-related products and services as part of our Hospital operations. These are not marketing communications and your authorization is not necessary. However, if you do not wish to receive these communications, please let us know by contacting the Privacy Officer. See contact information at the end of this Notice.