CONSENT FOR HEMODIALYSIS

I hereby authorize the performance of the procedure of Hemodialysis upon

________________________, under the direction of Dr._______________
Name of Patient

I have been fully informed by Dr._____________ , M.D., of the surgical and medical procedures
involved, and the problems and risks attendant thereto necessary to maintain my life in the
treatment of my condition, which is chronic kidney failure. I recognize that as with most
medical treatment, there are alternative methods of treatment, but I understand that hemodialysis
is the most likely to be beneficial in the present circumstances.

This consent is for regular and repeated hemodialysis treatments and for all additional
services deemed reasonable and necessary by my physician(s), for the optimal management of
my kidney failure or any complications of the hemodialysis procedures.

I understand that the hemodialysis treatment may involve administration of local anesthetic,
insertion of needles into the vascular access, administration of medications and intravenous fluids,
which includes by-products of blood. The complications from such procedures may include
blood loss, infection, sensitivity reaction and heart failure.

Print Name

Signature of Patient Witness

Or, Parent/Legal Guardian

Date Signed
 LIST OF PATIENT RIGHTS

Page 1 of 2

The dialysis unit has adopted the following list of patient rights and in accordance with
Federal Law CFR (494.70).

1. The patient has the right to be treated with respect, dignity, and recognition of
his or her individuality and personal needs, and sensitivity to his or her
psychological needs and ability to cope with ESRD.
2. The patient has the right to receive all information in a way that he or she can
understand.
3. The patient has the right to privacy and confidentiality in all aspects of
treatment.
4. The patient has the right to privacy and confidentiality in personal medical
records.
5. The patient has the right to be informed about and participate, if desired, in all
aspects of his or her care, and be informed of the right to refuse treatment, to
discontinue treatment, and to refuse to participate in experimental treatment.
6. The patient has the right to be informed about his or her right to execute
advance directives, and the facility’s policy regarding advance directives.
7. The patient has the right to be informed about all treatment modalities and
settings, including but not limited to, transplantation, home dialysis modalities
(home hemodialysis, intermittent peritoneal dialysis, continuous ambulatory
peritoneal dialysis, continuous cycling peritoneal), and in-facility hemodialysis.
The patient has the right to receive resource information for modalities not
offered by the facility, including information about alternative scheduling
options for working patients.
8. The patient has the right to be informed of facility policies regarding patient
care, including, but not limited to, isolation of patients.
9. The patient has the right to be informed of facility policies regarding the reuse
of dialysis supplies, including hemodialyzers.
10. The patient has the right to be informed by the physician, nurse practitioner,
clinic nurse specialist, or physician’s assistant treating the patient for ESRD of
his or her own medical status as documented in the patient’s medical record,
unless the medical record contains a documented contraindication.
 LIST OF PATIENT RIGHTS

Page 2 of 2
11. The patient has the right to be informed of services available in the facility and
charges for services not covered under Medicare.
12. The patient has the right to receive the necessary service outlined in the
patient plan of care.
13. The patient has the right to be informed of the rules and expectations of the
facility regarding patient conduct and responsibilities.
14. The patient has the right to be informed of the facility’s internal grievance
process.
15. The patient has the right to be informed of external grievance mechanisms
and processes, including how to contact the ESRD Network and the State
survey agency.
16. The patient has the right to be informed of his or her right to file internal
grievances or external grievances or both without reprisal of denial of
services.
17. The patient has the right to be informed that she or he may file internal or
external grievances, personally, anonymously or through a representative or
the patient’s choosing.
18. The patient has the right to be informed regarding the facility’s policies for
transfer, routine or involuntary discharge, and discontinuation of services to
patients.
19. The patient has the right to receive a written notice 30 days in advance of an
involuntary discharge except in the case of a patient who makes severe and
immediate threats to the health and safety of others.

Print Name

Signature of Patient
Or, Parent /Legal Guardian

Date Signed
 PATIENT GRIEVANCE PROCEDURE

All patients of this facility have the right to have their grievances handled promptly and
courteously.

A grievance is a request for an investigation of a complaint about a possible risk to the

health, safety, or well-being of a patient; or a situation where the patient is unnecessarily at
high risk. The grievance is to provide an opportunity for discussion and possible resolution of
problem(s) between patients and providers of care.

There is a "Suggestion/Grievance Box" located on the counter in the lobby, with forms
available. These may be signed or filed anonymously. All suggestions/grievances will be
handled promptly and with a goal of resolution.

The staff member to whom the patient's complaint is verbalized will report the grievance to
the Charge Nurse. If a solution to the grievance is not reached through this discussion, the
Charge Nurse will notify the Clinical Manager, who will discuss the grievance with the patient
and take appropriate action toward the solution, if possible. The Social Worker will be
utilized as appropriate.

If the patient's grievance cannot be resolved by the Clinical Manager, the Medical Director
will be alerted. He, will meet with the patient and discuss the grievance with the patient and
take appropriate action toward resolution, if possible.

If any patient or family members are not satisfied with the outcome or do not wish to use the
facility procedure, the patient can contact ESRD Network 18 or the California Department of
Health Service for assistance at the addresses below. Both organizations monitor care

Every patient has the right to file a grievance without restraint or interference, and without fear
of discrimination or reprisal.

Department of Health Services

Southern CA Renal Disease Council Licensing and Certification Division
ESRD Network 18 Riverside District Office
6255 Sunset Blvd., Suite 2211 625 East Carnegie Dr., Suite 280
Los Angeles, CA 90028 San Bernardino, CA 92408
(323) 962-2020 (909) 388-7170
(800) 637-4767 (888) 354-9203

Print Name Signature of Patient Date Signed

Or, Parent/Legal Guardian
 DIALYSIS CENTER RULES & PATIENT RESPONSIBILITIES

Page 1 of 2

Welcome to the Dialysis Center. In an attempt to provide safe and good quality care
to all patients equally, we have established the following dialysis center rules and
patient responsibilities:

1. The dialysis center schedules patients for treatment within certain hours. We
request patients arrive for their scheduled treatment 15 minutes prior to their
scheduled time. Patients will remain in the lobby until they are called-in to
the clinic by a staff member. Please refrain from walking into the clinic until
called as staff members are caring for others who require their attention. The
staff makes every effort to have all patients receive their treatments as
scheduled, however please be respectful of staff and other patients when
treatment times are delayed due to unforeseen circumstances.
2. It is the patient's responsibility to be on time for their scheduled treatment. If
the patient is late for dialysis, their dialysis treatment may be shortened, as it
may interfere with the other patients scheduled treatments. Patients need to
inform the clinic if they will not be arriving for their scheduled treatment or
need to make schedule changes.
3. Patients who request to travel to other units on a temporary basis are
required to provide advance notice to the Social Worker allowing time for
arrangements to be made. We recommend 30-day notice as many units
request updated vaccinations, lab work, etc., prior to placement. In addition,
we must know the return date to this facility. If there is to be a delay or
change in your scheduled return, please notify the unit as soon as possible. If
appropriate notice is not given, your regular scheduled treatment time may
not be available.
4. An attempt will be made to have patients be seated at the same chair and
pod on a regular basis, however due to staffing issues and various individual
treatment schedules, your chair may be changed from treatment-to-
treatment.
5. An attempt will be made to schedule patients at their preferred shift and time.
If the preferred time is not available you will be placed on a waiting list for
that time slot. Scheduling must take into consideration the needs of all the
patients in the unit, therefore, the patient might not always receive the
dialysis schedule of their choice.
6. Eating within the dialysis center is not recommended and should be at the
discretion of your physician. Visitors are not allowed to eat in the treatment
area.
7. This is a no-smoking facility, which includes the outside premises of the
facility.
 DIALYSIS CENTER RULES & PATIENT RESPONSIBILITIES

Page 2 of 2

8. Disruptive or unruly behavior in the dialysis center, on the part of a patient or

visitor is unacceptable. Any patient who demonstrates this type of behavior
may have their dialysis treatment terminated at that time and requested to
leave the unit. Patients who continue to disrupt the proper functioning of the
unit may be involuntarily discharged according to the facility policy. Visitors
will be requested to leave the facility and may be requested to not return.
9. Visitors will not be allowed in the unit while patients are being placed-on or
taken-off dialysis. Visitors are expected to remain with the patient and not
wander throughout the clinic, respecting the privacy of other patients.
Visitation is controlled by the Charge Nurse on duty. Children under the age
of 14 will not be permitted in the dialysis unit.
10. Patients will apply for Medicare, Medi-Cal or other insurance programs
when appropriate and to maintain coverage to the best of their ability.
11. To achieve maximum well-being, patients will notify their physician and
medical staff of their medical history and any medical changes, including
changes in medication.
12. Patients will acknowledge that failure to comply with the Nephrologists’
prescribed treatment times and schedule, medications, diet, and fluid
restrictions and other physician’s orders may result in declining health,
hospitalization and possibly death.

I have read and agree to comply with the above dialysis center rules and
regulations.

Print Name

Signature of Patient
Or, Parent/Legal Guardian

Date Signed
 PATIENT STANDARD OF CONDUCT AGREEMENT

Upon entering the unit, each patient shall have the Patient Standards of Conduct explained
to him/her. A statement signed by the patient stating that he/she has read, or has had read
to him/her, the Patient Standard of Conduct Agreement, and that he/she agrees to abide by
these standards, shall be placed Into the patient's chart. The standards are as follows:

1. Patients will treat other patients and staff members, with respect, dignity and consideration.
2. Patients will respect the rights of other patients to have a safe, clean, calm, adequate
treatment and treatment environment.
3. Patients will assure that their activities or that of their visitor’s activities do not interfere
with facility operations.
4. Patients will use the facility’s grievance procedure to voice concerns or complaints.
5. Patients will refrain from any form of verbal abuse, physical abuse, or sexual
harassment of other patients, staff or visitors.
6. Patients will arrive on time for their scheduled treatment and remain on dialysis for the
treatment time prescribed.
7. Patients will inform the facility if they are going to be late, or need to be rescheduled,
with the understanding that being late, may cause a patient not to receive their full
treatment.
8. Patients will cooperate with the staff member assigned to provide their care. Patients
will understand that they cannot require specific staff members to care for them. If a
patient is uncomfortable with a specific staff member assigned to their care, they will
make the Charge Nurse aware of the concern(s).
9. Patients will refrain from operating the dialysis equipment, removing or manipulating
their needles unless they have been trained and have permission to do so.
10. Patients will arrive at the unit free of the influence of illegal drugs, alcohol and
without a weapon. Patients also agree to refrain from having them in their
possession while on the premises of the unit.
11. Patients will agree to observe the law and understand that the consequences for
breaking the law apply to their conduct at the facility.

As stated above, patients are expected to abide by these standards of conduct. If a patient
behaves in a manner not consistent with the standards of the unit, the Facility Head Nurse,
Social Worker, Physician, Administrator, as applicable, will discuss the negative behaviors
and /or actions with the patient. Should the behavior continue and be detrimental to the
proper functioning of the unit; the patient may be involuntarily discharged from the dialysis
facility. The facility staff will follow the Involuntary Discharge regulations set forth by Federal
law CFR §494.180 (f).
The Agreement reads as follows:

The Patient Standards of Conduct has been read and fully explained to me. I
agree to abide by these standards at all times while registered as a patient at the
clinic: ________________________.

Print Name Signature of Patient

Or, Parent/Legal Guardian

Date Signed Signature of Staff

 Authorization To Release Medical Information and Payment Benefits

Patient Name:________________________________________

____I authorize the clinic_________________ to release medical information which

the insurance company may request concerning my illness or injury.

____I authorize payment of medical benefits to be made directly to the clinic

_______________________ for insurance claims submitted on my behalf. I
further understand that I am financially responsible to clinic_______________
for charges not covered by this assignment.

A copy of the authorization shall be considered as valid as the original.

Print Name

Signature of Patient
Or, Parent/Legal Guardian

Date Signed
 Authorization To Release Information to Other Family

I,______________________________authorize

___ Kidney Institute of the Desert

81-715 Dr. Carreon Blvd., Suite B-2, Indio, CA 92201

___La Quinta Kidney Center

43576 Washington Street, Suite 101, La Quinta, CA 92253

___Kidney Institute at Eisenhower Medical Center

39000 Bob Hope Dr., Probst Building, Suite 103, Rancho Mirage, CA 92270

___Coachella Kidney Institute

1413 6th Street, Coachella, CA 92236

To release information to and to exchange information with

the following family member(s) or other(s):

Name_____________________Phone____________________

Name_____________________Phone____________________

Name_____________________Phone____________________

I understand that purpose of the release/exchange of information is to

coordinate my dialysis treatment and to increase family/other
understanding of the dialysis treatment process.

Print Name

Signature of Patient
Or, Parent /Legal Guardian

Date Signed
 Authorization To Release Medical Information

The undersigned does hereby authorize the release of information

To:________________________________________________

From:______________________________________________

For Patient:__________________________________________

Signature of Patient:___________________________________

Date:___________ This authorization is good for up to one year.

Please send the following reports:

History and Physical

Discharge Summary
EKG-reports
All x-Ray Reports
Operation Reports
All Consults
Most Recent Lab Results
Social Worker Assessment
Nutrition Assessment
Other

THANK YOU

____________