Your Rights as Our Patient
Access to Care
- Receive appropriate medical care regardless of race, religion, gender, national origin, or disability
- Obtain emergency care when needed
- Know the names and roles of healthcare providers involved in your care
Information and Communication
- Receive clear explanations about your condition and treatment options
- Access your medical records as permitted by law
- Receive detailed information about service charges and payment policies
- Obtain interpreter services if needed
Privacy and Dignity
- Have your privacy protected during examinations and discussions
- Be treated with respect and consideration
- Have your medical information kept confidential as per HIPAA regulations
Treatment Choices
- Participate in decisions about your healthcare
- Refuse treatment as permitted by law
- Receive information about advance directives
- Request a second opinion
Your Responsibilities as Our Patient
Providing Information
- Provide accurate and complete medical history
- Inform us about current medications and supplements
- Report any changes in your health condition
- Update contact and insurance information
Following Treatment Plans
- Follow the agreed-upon treatment plan
- Attend scheduled appointments
- Notify us 24 hours in advance if unable to keep appointments
- Take medications as prescribed
Financial Obligations
- Provide current insurance information
- Pay copayments at time of service
- Meet financial obligations promptly
- Contact us if you need payment arrangements
Respectful Conduct
- Treat staff and other patients with respect
- Follow facility rules and regulations
- Refrain from disruptive behavior
- Respect the privacy of others
Acknowledgment
I have read and understand my rights and responsibilities as outlined above.
Patient Name: _________________ Date: _________________
Signature: _________________