Patient Forms

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PATIENT/REPRESENTATIVE/SURROGATES RIGHTS AND RESPONSIBILITIES (Mostrar en español)


  1. The patient/representative/surrogate has the right to courteous, considerate and respectful care provided in a safe and secure setting free from all forms of abuse and harassment.
  2. The patient/representative/surrogate has the right to obtain from his physician complete and current information concerning his diagnosis, treatment and prognosis in terms the patient/representative/surrogate can be reasonably expected to understand. When it is not medically advisable to give such information to the patient, the information should be made available to an appropriate person on his behalf. He/she has the right to know, by name, the physician responsible for coordinating his/her care.
  3. The patient/representative/surrogate has the right to receive from his physician information necessary to give informed consent prior to the start of the procedure and/or treatment. Except in emergencies, such information should include but not necessarily be limited to their diagnosis, the specific procedures and/or treatments, the medically significant risks involved prognosis and the probable duration of incapacitation. Where medically significant alternatives for care or treatment exist, or when the patient/representative/surrogate request information concerning medical alternatives, the patient/representative/ surrogate has the right to such information.
  4. The patient/representative/surrogate has the right to participate in decisions involving his/her care except when contraindicated for health reasons and to refuse treatment to the extent permitted by law and to be informed of the medical consequences of his action.
  5. 5. The patient has the right to every consideration of his privacy concerning his own medical care program. Case discussion, consultation examination and treatment are confidential and should be conducted discreetly. Those not directly involved in his care must have the permission of the patient/representative/surrogate to be present.
  6. The patient/representative/surrogate has the right to expect that communications and records pertaining to his care should be treated as confidential.
  7. The patient/representative/surrogate/representative/surrogate has the right to expect that within its capacity an ASC must make reasonable response to the request of a patient/representative/surrogate for services. The Facility must provide evaluation, service and/or referral as indicated by the urgency of the case. When medically permissible, a patient may be transferred to another health care facility after he has received complete information and explanations concerning the needs for and alternatives to such a transfer. The institution to which the patient is to be transferred must first have accepted the patient for transfer.
  8. The patient/representative/surrogate has the right to obtain information as to any relationship of his facility to other health care and educational institutions, insofar as his care is concerned, The patient/representative/surrogate/representative/surrogate has the right to obtain information as to the existence of any professional relationships among individuals, by name, who are treating him.
  9. The patient/representative/surrogate has the right to be made aware of their physician’s partial ownership of the surgical facility and that they have the right to have surgery performed at any other facility where their surgeon has privileges.
  10. The patient/representative/surrogate has the right to be advised when the facility proposes to engage in or perform human experimentation affecting his care or treatment. The patient/representative/surrogate has the right to refuse to participate in such research projects.
  11. The patient/representative/surrogate has the right to expect reasonable continuity of care and to know in advance what appointment times and physicians are available and when. The patient/representative/surrogate has the right to expect that the facility will provide a mechanism whereby his physician or a delegate of the physician of the patient continuing health care requirements following discharge informs him.
  12. The patient/representative/surrogate has the right to facility payment plans and to examine and receive an explanation of his bill regardless of the source of payment.
  13. The patient/representative/surrogate has the right to know what Facility rules and regulations apply to his conduct as a patient/representative/surrogate; e.g., the patient/representative/surrogate is responsible for providing information about his/her health, including past illnesses, hospitalizations and medication. The patient/representative/surrogate is responsible for asking questions to seek information or clarification of things not understood and for advising the physician if the decision is made to stop the treatment plan. The patient/representative/surrogate is responsible for providing payment information and making arrangements to pay.
  14. The patient has the right to receive service(s)without regard to age, race, color, sexual orientation, religion, marital status, sex, national origin, physical handicap, source of payment or sponsor.
  15. The patient/representative/surrogate has the right to be informed of the support services available at the center, including the availability of an interpreter.
  16. The patient/representative/surrogate has the right to be informed of the provisions for off-hour emergency coverage.
  17. The patient/representative/surrogate has the right to be informed of the charges for service eligibility for third-party reimbursements and. when applicable, the availability of free or reduced cost care.
  18. The patient, who is Medicare eligible, has the right to know, upon request and in advance of treatment, whether the facility accepts the Medicare assignment rate.
  19. The patient/representative/surrogate has the right to receive an itemized copy of his/her account statement upon request.
  20. The patient/representative/surrogates has the right to voice grievances and recommend changes in policies and services to the center’s staff, the operator and the governing state agency without fear of reprisal.
  21. The patient/representative/surrogate has the right to express complaints about the care and services provided to Libby Godfrey 3099 River Road South Suite 100 Salem, Oregon 97302 phone 503-361-3094 and to have the center investigate such complaints. The center is responsible for providing the patient/representative/surrogate with a written response within 30- days if requested by the patient/representative/surrogate, indicating the findings of the investigation. The center is also responsible for notifying the patient/representative/surrogate that if the patient/representative/surrogate is not satisfied by the center response, the patient/representative/surrogate may complain to the Public Health Division PO Box 14450 Portland, Oregon 97293-9929 Telephone 971-673-0540 E-mail mailbox.hclc@state.or.us or the patient/representative/surrogate may contact the Medicare Ombudsman Office directly at WWW.Medicare.gov/claims-and-appeals/medicare-rights/get-help/ombudsman.html
  22. The patient/representative/surrogate has right to review his/her record and to approve or refuse the release or disclosure of the contents of his/her medical record to any health care practitioner and/or health care facility except as required by law or third – party payment contract.
  23. The patient/representative/surrogate has the right to expect that marketing and/or advertising conducted by the facility is not misleading.
  24. The patient has the right to have an advance directive, such as a Living Will or health care proxy. These documents express the patient/representative/surrogate’s choices about their future care or name someone to decide if he/she cannot speak for himself/herself. If the patient has a written advance directive, a copy should be provided to the facility.
  25. The patient has the right to expect that the staff, who are all committed to pain prevention and management, will believe his/her report of pain and will respond quickly to provide information about pain and relief measures.
  26. The patient/representative/surrogate is responsible for providing information about past illnesses, hospitalizations, medications, and other matters relating to their health and to answer all questions concerning these matters to the best of their ability.
  27. The patient/representative/surrogate is responsible for being considerate of other patient/representative/surrogates and to see that family members are also considerate, especially in regards to smoking, noise and visitation policy.
  28. The patient/representative/surrogate is responsible for being respectful of others, their property. and the property of the facility and its personnel.
  29. The patient/representative/surrogate is responsible for promptly arranging for the payment of bills and provides necessary information for insurance processing.
  30. The patient/representative/surrogate is responsible for keeping all appointments promptly at their scheduled time or contacting staff as early as possible if a scheduled appointment cannot be kept.
  31. The patient/representative/surrogate is responsible for following instructions and the health care plan recommended by the health care provider and for asking questions if information is not understood.
  32. The patient/representative/surrogate is responsible for informing staff of physical changes experienced during treatment.
  33. The patient/representative/surrogate is responsible upon discharge by staff- to maintain the follow-up treatment recommended.
  34. The patient is responsible for asking for pain relief when the pain first begins and for providing help in assessing such, as well as notification if the pain is not relieved as expected.
  35. The patient/representative/surrogate is responsible for inquiring as to expectations regarding pain and pain management as well as discussions regarding relief options and concerns regarding pain medication.