Notice of Patient
Responsibilities
This
form is meant to inform you, the patient, as well as your
family that in addition to rights, you have responsibilities
while undergoing medical care. If there are any questions
regarding the contents of this form please notify any staff
member.
Keep
Your Health Care Providers Accurately Informed
You
(or your parent or legally designated representative) have the
responsibility to provide, to the best of your knowledge,
accurate and complete information about present complaints,
past illnesses, hospitalizations, medications and other
matters relating to your health, including unexpected changes
in your condition.
Follow
Your Treatment Plan
You
(or your parent or legally designated representative) are
responsible for following the treatment plan recommended by
the physician. This
may include following the instructions of health care
personnel as they carry out the coordinated plan of
care/services and implement the physician’s orders and as
they enforce the applicable practice rules and regulations.
Keep
Your Appointments
You
(or your parent or legally designated representative) are
responsible for keeping appointments and, when unable to do so
for any reason, for notifying this practice.
Be
Responsible for any Decision You Make Not to Follow Your
Treatment Plan
You
(or your parent or legally designated representative) are
responsible for your actions if the physician’s instructions
are not followed. If
you cannot follow through with the prescribed treatment plan,
you are responsible for informing the physician.
Be
Responsible For Your Financial Obligations
You
(or your parent or legally designated representative) are
responsible for assuring that the financial obligations of
health care/services are fulfilled as promptly as possible,
and for providing information for insurance.
Comply
with Rules of this Facility Regarding Patient Care and Conduct
of our Visitors
You
(or your parent or legally designated representative) are
responsible for following practice rules and regulations
affecting patient care/services and conduct.
Be
Considerate of Others
You
(or your parent or legally designated representative) are
responsible for being considerate of the rights of other
patients and personnel, and for assisting in the control of
noise, smoking and the number of visitors.
You are also responsible for being respectful of the
practice property as well as property of other persons
visiting the practice.
Be
Responsible for Your Own Lifestyle Choices
Your
health depends not just on your care/services but in the long
term, on the decisions you make in daily life.
You are responsible for recognizing the effect of
lifestyle of your personal life.
Notice of Patient
Rights
This
form is meant to inform you, the patient, as well as your
family that you have rights and responsibilities while
undergoing medical care. If there are any questions regarding
the contents of this form please notify any staff member.
Access to Care
Patients
shall be provided impartial access to treatment or
accommodations as to their requests and needs for treatment or
service that are within this practice’s capacity,
availability, stated mission, and applicable law and
regulation. This
is regardless of race, creed, sex, national origin, religion,
disability/handicap or source of payment of care/services.
Respect and Dignity
Every patient,
whether adult, adolescent, or newborn, has the right to
considerate, respectful care/services at all times and under
all circumstances, with recognition of his or her personal
dignity and his or her psychosocial, spiritual, and cultural
variables that influence the perceptions of illness.
Privacy
and Confidentiality
The
patient or his or her parent or legally designated
representative has the right, within the law, to personal and
informational privacy, as manifested by the right to:
·
Wear
appropriate personal clothing and religious or other symbolic
items, as long as they do not interfere with diagnostic
procedures or treatment.
·
Be
interviewed and examined in surroundings designed to assure
reasonable audiovisual privacy.
This includes the right to have a person of one’s own
sex present during certain parts of a physical examination,
treatment, or during a procedure performed by a health
professional of the opposite sex.
This also includes the right not to remain disrobed any
longer than is required for accomplishing the medical purpose
for which the patient was asked to disrobe.
·
Expect
that any discussion or consultation involving the patient’s
case—whether he or she is an adult, adolescent, or
newborn—will be conducted discreetly, and that individuals
not directly involved in care/services will not be present
without the patient’s permission.
·
Have
the right to review his or her medical records and have the
information explained, except when restricted by law.
·
Have
the medical records read only by individuals directly involved
in the treatment or the monitoring of its quality and by other
individuals only on the patient’s or his or her parent or
legal designated representative’s written authorization.
When the records are released to insurers, that
confidentiality is emphasized.
·
Expect
all communications and other records pertaining to
care/services of the individual, including the source of
payment for treatment, to be treated as confidential.
·
Request
a transfer to another treatment room if another patient or
visitor is unreasonably disturbing him.
Personal
Safety
The
patient, whether adult, adolescent or newborn, has the right
to expect reasonable safety insofar as the clinic practices
and environment are concerned.
Identity
The
patient or his or her parent or legally designated
representative has the right to know the identity and
professional status of individuals providing service to the
patient, and to know which physician or other practitioner is
primarily responsible for his or her care/services.
This includes the right to know of the existence of any
professional relationship among individuals who are treating
him or her, as well as the relationship of the practice to any
other health care/services or educational institution involved
in his or her care/services. Participation by patients in
clinical training programs or research should be voluntary.
Information
The patient or his
or her parent or legally designated representative has the
right to obtain from the practitioner responsible for
coordination of his or her care/services complete and current
information concerning his or her diagnosis (to the degree
known), treatment and any known prognosis.
This information should be communicated in terms the
patient or his or her parent or legal designated
representative can reasonably be expected to understand.
When it is not medically advisable to give such
information to the patient, the information should be made
available to a legally authorized individual.
Communication
The
patient or his or her parent or legally designated
representative has the right of access to people outside the
clinic by means of visitors and by verbal and written
communication. When
the patient or his or her parent or legally designated
representative does not speak or understand the predominant
language of the community, he or she should have access to an
interpreter. This
is particularly true where language barriers are a continuing
problem.
Consent
The
patient or his or her parent or legally designated
representative has the right to the information necessary to
enable him or her, in collaboration with the health care
practitioner, to make treatment decisions involving his or her
health care/services.
·
To
the degree possible, this should be based on a clear, concise
explanation of his or her condition and of all proposed
technical side effects, problems related to recuperation, and
probability of success.
·
The
patient should not be subjected to any procedure without
voluntary, competent, and understanding consent by the
individual or by his or her parent or legal designated
representative. Where
a medically significant need for care/services or treatment
exists, the patient or his or her parent or legal designated
representative shall be so informed.
·
The
patient or his or her parent or legally designated
representative has the right to know who is responsible for
authorizing and performing the procedures or treatment.
·
The
patient or his or her parent or legally designated
representative shall be informed if the clinic proposes to
engage in or perform human experimentation or other research
or educational projects affecting his or her care/services or
treatment, and the patient has the right to participate in any
such activity. If
the patient chooses not to take part, he or she shall receive
the most effective care/services the clinic otherwise
provides.
Consultation
The patient or his
or her parent or legally designated representative has the
right to accept medical care/services or to refuse treatment
to the extent permitted by law and to be informed of the
medical consequences of such refusal.
When refusal of treatment by the patient or his or her
parent or legal designated representative prevents the
provision of appropriate care/services in accordance with
ethical and professional standards, the relationship with the
patient may be terminated upon reasonable notice.
Transfer
and Continuity of Care
A
patient has the right to expect that the clinic/facility will
give necessary health services to the best of its ability.
Treatment, referral or transfer may be recommended. If
transfer is recommended or requested, the patient will be
informed of risks, benefits and alternatives. The patient will
not be transferred until the other institution agrees to
accept such patient.
Charges
Regardless
of the source of payment for the individual’s care/services,
the patient or his or her parent or legal designated
representative has the right to request and receive an
itemized and detailed explanation of his or her total bill for
services rendered in the clinic. The patient has the right to
timely notice prior to termination of his or her eligibility
for reimbursement by any third-party payer for the cost of his
or her care/services
Rules
and Regulations
The
patient or his or her parent or legally designated
representative should be informed of the clinic rules and
regulations applicable to his or her conduct as a patient.
Patients are entitled to information about the mechanism for
the initiation, review and resolution of patient complaints.
Delineation
of Patient’s Rights
The
rights of the patient may be delineated on behalf of the
patient, to the extent permitted by law, to the patient’s
guardian, next of kin or legally authorized responsible person
if the patient:
·
Has
been adjudicated incompetent in accordance with the law
·
Is
found to be medically incapable of understanding the proposed
treatment or procedure
·
Is
unable to communicate his or her
wishes regarding treatment
·
Is
a minor
NOTICE
OF PRIVACY PRACTICES
As Required by the Privacy Regulations
Created as a Result of the Health Insurance Portability and
Accountability Act of 1996 (HIPAA)
THIS
NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A
PATIENT OF THIS PRACTICE) MAY BE USED AND DISCLOSED, AND HOW
YOU CAN GET ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH
INFORMATION.
PLEASE
REVIEW THIS NOTICE CAREFULLY.
1.
We have a legal, ethical, and moral obligation to
protect your confidentiality.
Any information about you and/or your family will be
held strictly confidential by all employees.
No discussions about you outside of the patient care
framework will be allowed, and any conversation between staff
members that pertains to delivering you quality care will be
held in a confidential and professional manner.
2.
In order to provide quality care to you, as well as
operate this office in an efficient manner, we will need to
access your private health care information for purposes of
treatment, payment and operations [such as quality assurance].
In using this information this office will comply with
all state and federal laws pertaining to your privacy rights,
including the Privacy and Security protections provided to you
by the Health Insurance Portability and Accountability Act
[HIPAA].
3.
Specifically, we will need to disclose your private
information under the following circumstances:
a)
Sharing
Information for Purpose of Treatment:
We will share information with all members of your
treatment team, both within this office and with other
providers [personal and institutional] in order to provide you
with quality care and the educational/wellness program
specified in your insurance plan.
b)
Sharing
information for Purpose of Payment:
We will share all necessary information with your
insurer[s], payer[s], governmental entities [such as Medicare,
etc.] and their representatives [including, but not limited to
benefit determination and utilization review] as well as our
representatives involved in the billing process [including,
but not limited to claims representatives, data warehouses,
and billing companies].
c)
Sharing
of Information for Purpose of Operations:
We will share all information necessary for ongoing
operations of this office, including [but not limited to]
credentialing processes, peer review, accreditations and
compliance with all federal and state laws.
4.
Your consent for use and disclosure of information as
described may be revoked in writing at anytime.
Please notify the office/Privacy Officer if you ever
decide to revoke your consent.
5.
Your specific authorization will be required for
release of information not included above. Your authorization
will need to be in writing and it will be specific to the
disclosure requested. Incidences
which may require authorization under the HIPAA regulations
include [but are not limited to] some marketing purposes, the
disclosure of any psychotherapy records in our possession and
disclosure for fundraising by any entity.
6.
Your consent will give us authorization to fax or leave
messages on your answering machine/service, regarding
appointment reminder calls, test results, or other messages
relating to your care in this office. It will also give us
authorization to send postcards reminding you to schedule an
appointment.
7.
This office will not release any information other than
those incidents described above, unless disclosure is required
by law, a court, a legal process or government agencies.
