Patient Rights and Responsibilities

PATIENT’S BILL OF RIGHTS

SPECIALTY SURGERY CENTER believe that patients’ rights are of primary importance for proper and complete health care delivery. Each patient receiving service at our facility shall have the following rights:

1. To be informed of these rights and given an explanation for these rights in terms he/she can understand.

2. To be informed of services available in the facility, of names, of professional status/credentials/insurance of the personnel providing and/or responsible for his/her care, and of fees and related charges, including payment, fee, deposit and refund policy of the facility and any charges for service not covered by sources of third party payment or not covered by the facility’s basic rate.

3. He/she also shall have a right to change physicians, refuse or allow their participation in his/her treatment.

4. To receive from his/her physician(s) or clinical practitioner(s), in understandable terms, an explanation of his/her complete medical/health condition or diagnosis, evaluation, recommended treatment, options (including the option of no treatment), risk(s) of treatment and expected result(s). If this information would be detrimental to his/her health, or if he/she is not capable of understanding the information, the explanation shall be provided to his/her next kin or guardian. This release of information to the next of kin or guardian, along with the reason for not information the patient directly, shall be documented in his/her medical record.

5. To participate in the planning of his/her treatment and to refuse medication and treatment. Such refusal shall be documented in his/her medical record.

6. He/she may refuse or choose to participate in experimental research, including the investigation of new drugs and medical devices.

7. To voice and receive a verbal/written response to grievances or recommended changes in policies and services to facility personnel, the governing authority and/or outside representatives of his/her choice, either individually or as a group, and free form restraint, interference, coercion, discrimination or reprisal.

8. To be free from mental and physical abuse, free from exploitation and free from use of restraints, unless they are authorized by physician for a limited period of time to protect the patient or others from injury. Drugs and other medications shall not be used for discipline of patients or for the convenience of facility personnel.

9. To confidential treatment of information about any patient. Information in the patient’s medical record shall not be released to anyone outside the facility without his/her approval, unless another healthcare facility to which he/she was transferred requires the information; or unless the information is required and permitted by law, a third party contract or a peer review; or unless the information is needed by the Tennessee State Department of Health for statutorily authorized purposes.

10. Treated with courtesy, consideration, respect and recognition of his/her dignity and individuality and the right to privacy, including but not limited to, auditory and visual privacy and medical record information.

11. To not be discriminated against because of age, race religion, sex, nationality, or deprived of any constitutional, civil and/or legal rights.

12. To request information regarding services available at the Center, provisions for after-hours and emergency care and advanced directives living will.

13. To receive information about fees for services and payment policies.

PATIENT’S RESPONSIBILITIES

Each patient receiving service at our Surgical Center shall have the following responsibilities:

1. To give us complete and detailed information regarding his/her past and present medical surgical conditions.

2. To inform us of any and all drugs/herbal supplements taken, either prescription or non-prescription.

3. To assume complete responsibility for payment of services provided.

4. Patients are responsible for medical and related consequences resulting from the refusal of treatment or from not following instructions of physicians and/or Center’s personnel.

5. To be considerate of the assets and employees of the Center.

CONTACT INFORMATION:

acceptance & receipt of the patient’s bill of rights:

**(to be completed at facility on day of surgery, below info given for reference only)**

The ORAL FACIAL SURGERY CENTER d/b/a SPECIALTY SURGERY CENTER has issued, you the patient, a copy of your Patient Bill of Rights and your Patient Responsibilities.

This signature form will be retained in your Patient File for one year.

Signature of receipt of this document means that you physically received a copy of your Patient Bill of Rights and your Patient Responsibilities and does not imply anything other.

Patient Signature: __________________________________ Date:_______________

Patient Guardian or Representative: __________________________Date: _________

Relationship to the Patient: _______________________________________________

Witness: __________________________________________ Date: _______