PATIENT’S STATEMENT OF RIGHTS AND RESPONSIBILITIES

The staff of this health care facility recognizes you have rights while a patient receiving medical care. In return, there are responsibilities for certain behavior on your part as the patient. This statement of rights and responsibilities is posted in our facility in at least one location that is used by all patients.

Your rights and responsibilities include:

A patient, patient representative or surrogate has the right to

• Receive information about rights, patient conduct and responsibilities in a language and manner the
patient, patient representative or surrogate can understand.
• Be treated with respect, consideration and dignity.
• Be provided appropriate personal privacy.
• Have disclosures and records treated confidentially and be given the opportunity to approve or
refuse record release except when release is required by law.
• Be given the opportunity to participate in decisions involving their health care, except when such
participation is contraindicated for medical reasons.
• Receive care in a safe setting.
• Be free from all forms of abuse, neglect or harassment.
• Exercise his or her rights without being subject to discrimination or reprisal with impartial
access to medical treatment or accommodations, regardless of race, national origin, religion,
physical disability, or source of payment.
• Voice complaints and grievances, without reprisal.
• Be provided, to the degree known, complete information concerning diagnosis, evaluation, treatment
and know who is providing services and who is responsible for the care. When the patient’s medical
condition makes it inadvisable or impossible, the information is provided to a person designated by
the patient or to a legally authorized person.

• Exercise of rights and respect for property and persons, including the right to
o Voice grievances regarding treatment or care that is (or fails to be) furnished.
o Be fully informed about a treatment or procedure and the expected outcome before it is performed.
o Have a person appointed under State law to act on the patient’s behalf if the patient is adjudged
incompetent under applicable State health and safety laws by a court of proper jurisdiction. If a
State court has not adjudged a patient incompetent, any legal representative designated by the
patient in accordance with State law may exercise the patient’s rights to the extent allowed by
State law.

• Refuse treatment to extent permitted by law and be informed of medical consequences of this action.
• Know if medical treatment is for purposes of experimental research and to give his consent or
refusal to participate in such experimental research.
• Have the right to change primary or specialty physicians or dentists if other qualified physicians
or dentists are available.
• A prompt and reasonable response to questions and requests.
• Know what patient support services are available, including whether an interpreter is available if
he or she does not speak English.
• Receive, upon request, prior to treatment, a reasonable estimate of charges for medical care and
know, upon request and prior to treatment, whether the facility accepts the Medicare assignment
rate.
• Receive a copy of a reasonably clear and understandable, itemized bill and, upon request, to have
charges explained.
• Formulate advance directives and to appoint a surrogate to make health care decisions on his/her
behalf to the extent permitted by law and provide a copy to the facility for placement in his/her
medical record.
• Know the facility policy on advance directives.
• Be informed of the names of physicians who have ownership in the facility.
• Have properly credentialed and qualified healthcare professionals providing patient care.

A patient, patient representative or surrogate is responsible for

• Providing a responsible adult to transport him/her home from the facility and remain with him/her
for 24 hours, unless specifically exempted from this responsibility by his/her provider.
• Providing to the best of his or her knowledge, accurate and complete information about his/her
health, present complaints, past illnesses, hospitalizations, any medications, including over-the-
counter products and dietary supplements, any allergies or sensitivities, and other matters
relating to his or her health.
• Accept personal financial responsibility for any charges not covered by his/her insurance.
• Following the treatment plan recommended by his health care provider.
• Be respectful of all the health providers and staff, as well as other patients.
• Providing a copy of information that you desire us to know about a durable power of attorney,
health care surrogate, or other advance directive.
• His/her actions if he/she refuses treatment or does not follow the health care provider’s
instructions.
• Reporting unexpected changes in his or her condition to the health care provider.
• Reporting to his health care provider whether he or she comprehends a contemplated course of action
and what is expected of him or her.
• Keeping appointments.

COMPLAINTS

Please contact us if you have a question or concern about your rights or responsibilities. You can ask any of our staff to help you contact the Administrative Director at the surgery center. Or, you can call

(805) 275-0200

We want to provide you with excellent service, including answering your questions and responding to
your concerns.

You may also choose to contact the licensing agency of the state,
California Department of Public Health
PO Box 997377, MS 0500
Sacramento, CA 95899-7377
(916) 558-1784

If you are covered by Medicare, you may choose to contact the Medicare Ombudsman at 1-800-MEDICARE
(1-800-633-4227) or on line at http://www.medicare.gov/claims-and-appeals/medicarerights/get-help/ombudsman.html

. The role of the Medicare Beneficiary Ombudsman is to ensure that Medicare beneficiaries receive the
information and help you need to understand your Medicare options and to apply your Medicare rights and protections.