Patient Rights and Responsibilities Agreement

Patient Rights

Access to Care

• Receive appropriate medical care regardless of race, religion, gender, age, or disability
• Have family/friend present during care when appropriate
• Access your medical records as permitted by law

Quality of Care

• Receive respectful care that maintains your dignity
• Participate in all treatment decisions
• Receive complete information about diagnosis, treatment, and prognosis
• Obtain a second medical opinion when desired

Privacy and Safety

• Have all medical information kept confidential per HIPAA regulations
• Receive care in a safe environment
• Be free from all forms of abuse or harassment
• Receive detailed information about advance directives

Patient Responsibilities

Communication

• Provide accurate and complete medical history
• Inform healthcare providers about changes in health status
• Ask questions when instructions are unclear

Compliance

• Follow the prescribed treatment plan
• Attend scheduled appointments
• Provide current insurance information
• Pay bills in a timely manner

Conduct

• Treat staff and other patients with respect
• Follow facility rules and regulations
• Respect others' privacy

Acknowledgment

I have read and understand my rights and responsibilities as outlined above.

Patient Name: _________________________

Signature: ____________________________

Date: ________________________________

Witness: ______________________________