(a) During the intake procedure before incarceration in the City of Parma Jail, all prisoners shall provide the booking officer with their health insurance card, or, in the alternative, the name of their insurance provider, the name and address of their employer and/or the name of the group coverage of such health insurance.
(b) When a prisoner presents this health care insurance information to the booking officer, the prisoner will be requested to sign a formal consent form, as set forth below, in which the prisoner agrees to the disclosure of this information, agrees that he or she is acting voluntarily and agrees to let the Parma Police Department disclose this health insurance information to the hospital.
(c) Once this consent form is signed by the prisoner, the information will be forwarded to the hospital. The insurer will be billed for the prisoner's medical costs. Only if the insurer denies payment will the City of Parma then be responsible for payment.
RELEASE OF PRISONER HEALTH INSURANCE INFORMATION
TO PARMA COMMUNITY GENERAL HOSPITAL
Authorization to release information:
I hereby authorize the Parma Police Department to release all my health insurance information given during the intake procedure, to the Parma Community General Hospital for billing purposes.
This is to certify that I agree to this disclosure to the billing of my insurance company and that I am acting voluntarily.
DATE SIGNATURE
(Ord. 181-93. Passed 7-19-93.)