Your Rights as Our Patient
Access to Care
- Receive care regardless of race, gender, age, religion, national origin, disability, or source of payment
- Receive emergency care when needed
- Know the names and roles of your healthcare providers
Respect and Dignity
- Be treated with respect and consideration
- Receive care in a safe environment
- Have your cultural and personal values respected
- Have your privacy protected (HIPAA)
Information and Communication
- Receive complete information about your diagnosis, treatment, and prognosis
- Access your medical records as permitted by law
- Receive information in a language you understand
- Be informed about proposed procedures and alternatives
Participation in Care Decisions
- Participate in decisions about your care
- Refuse treatment as permitted by law
- Receive information about advance directives
- Choose or change your healthcare provider
Your Responsibilities as Our Patient
Providing Information
- Provide accurate and complete medical history
- Report changes in your condition
- Inform us about medications, supplements, and allergies
- Provide accurate insurance and payment information
Following Treatment Plans
- Follow the recommended treatment plan
- Keep appointments or notify us of cancellations
- Accept responsibility for refusing treatment
- Follow pre-procedure preparation instructions
Financial Obligations
- Provide necessary insurance information
- Pay bills in a timely manner
- Work with our office on payment arrangements if needed
Conduct and Compliance
- Treat staff and other patients with respect
- Follow facility rules and regulations
- Respect the privacy of others
- Arrive on time for appointments
Acknowledgment
I have read and understand my rights and responsibilities as outlined above.
Patient Name: _________________
Date: _________________
Signature: _________________