Your Rights as a Patient
As a patient at [Urgent Care Name], you have the right to:
- Receive care regardless of race, color, religion, gender, sexual orientation, or disability
- Be treated with respect and dignity in a safe, clean environment
- Know the names and roles of healthcare providers involved in your care
- Receive clear explanations about your condition and treatment options
- Participate in decisions about your healthcare
- Privacy and confidentiality regarding your medical information
- Access your medical records as permitted by law
- Receive appropriate assessment and management of pain
- Voice concerns without fear of discrimination or retaliation
- Refuse treatment within the confines of the law
Your Responsibilities as a Patient
To ensure the best possible care, you are responsible for:
- Providing accurate and complete information about your medical history
- Informing staff about any changes in your health status
- Following the treatment plan recommended by healthcare providers
- Asking questions when you don't understand your care or treatment
- Showing respect to healthcare providers and other patients
- Providing accurate insurance and payment information
- Arriving on time for appointments
- Paying co-payments and outstanding balances as required
- Following facility rules and regulations
Financial Agreement
I understand that:
- Payment is expected at the time of service
- I am responsible for any charges not covered by insurance
- There may be separate billing for laboratory or imaging services
Acknowledgment
I have read and understand my rights and responsibilities as outlined above.
Patient Name: _________________________
Signature: ____________________________
Date: ________________________________
Witness: ______________________________