Outpatient Care Agreement
Please read and agree to the following terms and conditions before proceeding with new patient registration.
1
I agree to the healthcare services process at ST. Elisabeth Hospital as an outpatient.
2
I understand and acknowledge my rights and obligations as a patient as informed by the hospital staff.
3
I agree to the healthcare services at ST. Elisabeth Hospital as an outpatient according to medical needs. Healthcare services may include physical examinations, diagnostic tests such as radiology, laboratory, pathology, or other supporting examinations, as well as necessary medical procedures and equipment installation.
4
I understand that ST. Elisabeth Hospital guarantees the confidentiality of my personal health information, including diagnosis, laboratory results, and diagnostic test results used for treatment.
I authorize ST. Elisabeth Hospital to provide information regarding diagnosis, service results, and treatment if needed to process insurance/corporate/BPJS claims or to family members with my consent.
5
I understand and agree that ST. Elisabeth Hospital is not responsible for the loss, damage, or theft of personal valuables.
6
I understand, agree, and will pay all outpatient medical expenses. I understand and agree that if there are examination/procedure/treatment costs that are not covered or only partially covered by the guarantor, I am willing to pay the full or remaining balance incurred.
