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 complete information about your diagnosis, treatment, and prognosis
- Access your medical records as permitted by law
- Receive clear explanations about tests and treatments
- Participate in decisions about your care
- Receive information in your preferred language
Privacy and Confidentiality
- Have your medical information kept confidential
- Private consultations and examinations
- Review and receive copies of your medical records
Respect and Dignity
- Be treated with courtesy and respect
- Receive care in a safe environment
- Be free from all forms of abuse or harassment
Your Responsibilities as Our Patient
Providing Information
- Provide accurate and complete medical history
- Inform us about medications, including over-the-counter drugs
- Report changes in your condition
- Provide accurate insurance and payment information
Following Treatment Plans
- Follow the treatment plan recommended by your healthcare provider
- Attend scheduled appointments
- Inform us if you cannot follow the treatment plan
- Accept responsibility for refusing treatment
Financial Obligations
- Provide necessary information for insurance claims
- Pay bills in a timely manner
- Work with our billing office regarding payment arrangements
Conduct
- Treat staff and other patients with respect
- Follow facility rules and regulations
- Keep appointments or notify us of cancellations
- Refrain from disruptive behavior
Acknowledgment
I have read and understand my rights and responsibilities as outlined above.
Patient Name: _________________
Date: _________________
Signature: _________________