Fort Sanders Regional Medical Center ("Facility") CONDRA, KENNETH PAUL

Notice of Independent Contractor Status CMRN: 00603668

CH80850054 (9/21) Acct: F-5208801026

IMPORTANT NOTICE OF
INDEPENDENT CONTRACTOR STATUS
OF HEALTHCARE PRACTITIONERS
(NOT HOSPITAL EMPLOYEES OR AGENTS)

The medical treatment rendered to the PATIENT during his/her hospitalization will be
provided by independent healthcare practitioners. These independent practitioners include,
but are not limited to: attending and consulting physicians, surgeons, anesthesiologists,
cardiologists, radiologists, pathologists, neurologists, hospitalists, intensivists, emergency
room physicians, neonatologists, pediatricians, physician assistants, dentists, endodontists,
oral surgeons, nurse practitioners, midwives, certified registered nurse anesthetists, and other
healthcare professionals.

THE PATIENT (OR REPRESENTATIVE) ACKNOWLEDGES THAT INDEPENDENT

PRACTITIONERS ARE INDEPENDENT CONTRACTORS AND ARE NOT
EMPLOYEES OR AGENTS OF FACILITY, AND THE INDEPENDENT
PRACTITIONERS ARE NOT SUBJECT TO THE CONTROL AND SUPERVISION OF
THE FACILITY.

PATIENT (OR REPRESENTATIVE) AGREES THAT FACILITY IS NOT LIABLE OR

RESPONSIBLE FOR THE ACTS OR OMISSIONS OF HEALTHCARE
PROFESSIONALS NOT EMPLOYED BY FACILITY.

The PATIENT (or representative) further agrees that the execution of this document does not
in any way imply that Covenant Health, the FACILITY, or its unincorporated divisions are
responsible for or assume any liability for the activities of any such independent practitioners
or any other supplier of services that is not employed by the FACILITY.

I CERTIFY THAT I HAVE READ AND UNDERSTAND THIS NOTICE/DOCUMENT.

WITNESS SIGNED
(Patient or Representative)

DATE 03/25/2022 12:08 PM BY CONDRA, KENNETH PAUL

Relationship to Patient: SELF

Original to Medical Record Copy to Patient