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CONSENT FOR CARE AND SERVICES

52545-000 (9/2020) Page 1 of 4 CONSENT FOR CARE AND SERVICES 52545-000 (9/2020) Please read this form carefully. This CONSENT form explains how we provide care, share your information , receive payment for the SERVICES provided, and perform certain business functions. Unless it is an emergency, you must sign this form before receiving care. We cannot accept any changes to this form. Please let us know if you have questions or concerns about the information below. My CONSENT for Care and General Terms Who We Are: In this CONSENT , the term NorthShore we or us means: NorthShore University HealthSystem (including, but not limited to, Evanston Hospital, Glenbrook Hospital, Highland Park Hospital, Skokie Hospital, NorthShore Home and Hospice SERVICES , NorthShore Immediate Care, and any other NorthShore patient care location), certain organizations owned or controlled by NorthShore (the Affiliates ) including, NorthShore Medical Group and Swedish Covenant Health, and the physicians, nurses and other staff or employees of NorthShore and the Affiliates.

52545-000 (9/2020) Page 1 of 4 . CONSENT FOR CARE AND SERVICES. 52545-000 (9/2020) Please read this form carefully. This “Consent” form explains how we provide care, share your information, receive payment

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AUTHORIZATION FOR DISCLOSURE OF CONFIDENTIAL …

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Skokie, IL 60076-9877 Fax: (847) 982-6957 In Person: Bring to the hospital financial counselor by visiting a hospital central registration desk Call (847) 570-5000 or meet with a hospital financial counselor by visiting a hospital central registration desk For Swedish Hospital: Mail: Swedish Hospital Financial Service Center

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