Lucile Packard Children’s Hospital Stanford
STANFORD UNIVERSITY MEDICAL CENTER ● 725 Welch Road, Palo Alto, CA 94304
CORE DATA • OUTPATIENT TERMS AND
CONDITIONS OF SERVICE
Medical Record Number
Addressograph Stamp – Patient Name, Medical Record Number
L14315 6735 (8/17)
Page 1 of 2
White - Medical Records Yellow - Patient Copy
Please read this document carefully. Lucile Salter Packard Children’s Hospital (LPCH) requires the
Terms and Conditions of Service to be signed in its entirety, without alteration.
1. AUTHORIZED SIGNATURE. You may sign this form only if you are a competent adult over the age of 18 or a
minor who is permitted under state law to consent to treatment. If you are a minor who does not fall within the
limited exceptions provided under state law or are not competent to sign this form, the form must be signed by
a properly designated representative, such as a parent or legal guardian.
2. TERM OF AGREEMENT. The terms and conditions in this outpatient agreement will remain in effect for one
year from the date of signature. You will be asked to sign this agreement annually. At each clinic visit, you
will be asked to confirm that your demographic and insurance information is correct. If your insurance or
demographic information has changed, please inform the clinic staff.
3. MEDICAL CONSENT. I, the undersigned, consent to the general treatment and procedures that may be
performed during this hospitalization or as an outpatient (including emergency services). These procedures
may include but are not limited to laboratory procedures, x-ray examinations, medical or surgical treatment or
procedures, anesthesia, or hospital services provided to the patient under the general and special instructions
of the patient’s physician or surgeon. I understand that it is the responsibility of the patient’s physician to
obtain the patient’s informed consent when required for specific medical or surgical treatment and special
diagnostic or therapeutic procedures. I understand and agree that at the request of the attending physician,
allied health practitioners (such as physician assistants and nurse practitioners) may participate in the patient’s
4. TEACHING INSTITUTION. LPCH is a teaching facility, training physicians, surgeons, nurses and other health
care personnel. At the request, and under the supervision, of the attending physician, I agree that residents,
interns, medical students, post-graduate fellows, visiting faculty members and other health care personnel in
training may participate in the care of the patient. Certain medical services may be provided by individuals
who do not have a physician’s certificate but are qualified to participate in a special program as a visiting
5. PHOTOGRAPHY. I consent to the taking of pictures, videotapes or other electronic reproductions of the
patient’s medical or surgical condition or treatment, and the use of the pictures, videotapes or electronic
reproductions, for treatment or internal or external activities consistent with the Hospital’s mission, such as
education and research, conducted in accordance with Hospital policies.
6. LEGAL RELATIONSHIP BETWEEN LPCH AND PHYSICIANS. Except for those physicians under contract with
LPCH, such as faculty physicians practicing in the clinics, all physicians and surgeons furnishing services
to the patient are independent contractors with the patient and are not employees or agents of LPCH. The
undersigned understands that the patient is under the care and supervision of his or her attending physician
and that it is the responsibility of LPCH and its non-physician health care staff to carry out the instructions of
such physician or surgeon.
7. JOINT INFORMATION. The undersigned understands that patient information and records may be shared
between Stanford Hospital and Clinics and LPCH to facilitate patient care.
8. FINANCIAL AGREEMENT. For the services to be rendered (e.g., hospital, physician), the undersigned agrees
to accept full financial responsibility for the patient’s account in accordance with the regular rates and terms
of LPCH. This includes financial responsibility for all deductibles and copayments that may be required
by the patient’s insurance or health plan, including Medicare and Medi-cal. Should the patient’s account(s)
be referred to an attorney or a collection agency for collection, the undersigned further agrees to pay actual
attorneys’ fees and lawsuit-related expenses incurred in addition to other amounts due. When the services are
to be billed to insurance, a health plan or another payment source, then paragraphs 9 (Contracted Health Plan
Patients and Other Sources) and/or 10 (Assignment of Insurance Benefits) will also apply.