Your Rights as a Patient
Access to Care
- Receive quality dermatological care regardless of race, religion, gender, national origin, or disability
- Obtain complete information about your diagnosis, treatment, and prognosis in terms you can understand
- Access your medical records as permitted by law
Privacy and Dignity
- Have your privacy protected in accordance with HIPAA regulations
- Be treated with respect and dignity during all interactions
- Receive care in a safe and clean environment
Treatment Decisions
- Participate in decisions regarding your care
- Refuse treatment and be informed of medical consequences
- Receive information about alternative treatments
- Know the names and roles of healthcare providers involved in your care
Financial Information
- Receive detailed information about fees and payment policies
- Request and receive an itemized bill explanation
- Be informed about insurance coverage and financial assistance options
Your Responsibilities as a Patient
Providing Information
- Supply accurate and complete medical history
- Inform providers about current medications and supplements
- Report changes in your condition or concerns about your care
Following Treatment Plans
- Follow the prescribed treatment plan
- Keep scheduled appointments or provide adequate notice for cancellation
- Inform providers if you cannot follow treatment recommendations
Financial Obligations
- Provide accurate insurance and payment information
- Meet financial commitments for care received
- Work with the office to arrange payment plans if needed
Conduct
- Treat staff and other patients with respect
- Follow facility rules and regulations
- Refrain from disruptive behavior
Acknowledgment
I acknowledge that I have read and understand these rights and responsibilities.
Patient Name: _________________
Date: _________________
Signature: _________________