Patient Rights and Responsibilities

(555) 555-5555

As a patient of the surgery center, you have the right to:

1. Access to all treatments, or accommodations that are available or medically indicated, regardless of race, ethnicity, national origin, color, creed/religion, sex, gender identity, age, mental disability, or physical disability.

2. Considerate, respectful care at all times and under all circumstances with recognition of your personal dignity.

3. Respect of your personal privacy.

4. Exercise your rights free from any act of discrimination or reprisal.

5. Expect that all communications and records pertaining to your care will be keptconfidential, except as otherwise required by law.

6. Expect care in a safe and secure environment.

7. Be free from all forms of abuse or harassment.

8. Know the identity and professional status of individuals providing your service, and to know which physician or other practitioner is primarily responsible for your care.

9. A disclosure of physician financial interests or ownership in the surgery center.

10. Be informed of and to consent or withhold consent to any request to participate in research projects or to be interviewed for such purposes.

11. Be informed before and after your treatment with information regarding your health condition, diagnosis, expected prognosis, and expected outcome of care.

12. Reasonably informed participation in decisions involving your care. You should not be subjected to any procedure without your voluntary, competent, and understanding consent, or that of your legally authorized representative.

13. Consult with another specialist, at your own request and expense. You have the right to cease your relationship with your healthcare provider.

14. Refuse treatment to the extent permitted by law.

15. Have an advance directive, such as a living will or durable power of attorney for healthcare, and be informed as to the surgery center’s policy regarding advance directives, including, as applicable, a description of applicable state health and safety laws. If applicable and as requested, the surgery center will provide you official state advance directive forms.

16. Request information concerning fees for services and an itemized, detailed explanation of charges for all services provided.

17. Provide or refuse consent to any request to record, film, or use of images for purposes other than your care, and to request cessation of production of the recordings, films or other images at any time.

18. Be provided with language assistance service, free of charge, by a qualified interpreter if you are an individual with limited English proficiency or have a disability.

19. File a grievance regarding treatment or care that is (or fails to be) provided and receive a fair response from the surgery center within a reasonable amount of time. You may also file a grievance regarding your treatment or care with state and federal healthcare agencies or the surgery center’s accreditation agency. Contact information for filing a grievance is provided at the bottom of this notice.

If a patient is adjudged incompetent under applicable state laws by a court of proper jurisdiction, the rights of the patient are exercised by the person appointed under state law to act on the patient’s behalf.

If a state court has not adjudged a patient incompetent, any legal representative or surrogate designated by the patient in accordance with state law may exercise the patient’s rights to the extent allowed by state law.

As a patient of the surgery center, you are responsible for:

1. Providing accurate and complete information about present complaints, past illnesses, hospitalizations, medications, including any over-the-counter medications, dietary supplements, allergies, or any other matters relating to your health.

2. Reporting whether you clearly comprehend a planned course of action and what is expected of you and asking questions when you do not understand your care, treatment, or service or what you are expected to do.

3. Access to and/or requesting copies of your medical records and the ability to request amendments to your medical records.

4. Following the treatment plan provided by your physician and the surgery center.

5. Keeping appointments, and when unable to do so for any reason, to notify the doctor’s office.

6. Your actions if you refuse treatment or do not follow the doctor’s instructions.

7. Assuring that your financial obligations to the surgery center are fulfilled as promptly as possible.

8. Checking in at the reception desk upon each arrival so that the receptionist is aware of your presence.

9. Informing the surgery center about changes to your registration information, including anynew contact information.

10. Being considerate of the rights of other patients and surgery center personnel and for being respectful of the property of other persons and that of the surgery center.

11. Providing a responsible adult to transport you home from the surgery center and remain with you for 24 hours if required by your provider.

12. Informing your provider about any advance directive, such as a living will or durable power of attorney for healthcare, you may have that could affect your care.

Grievance Reporting

The surgery center has established a grievance procedure for documenting the existence, submission, investigation, and disposition of a patient’s written or verbal grievances. You may contact the surgery center, governmental agencies, and accreditation agency at the contact information below with any concerns, complaints, or grievances.

Surgery Center	Palos SurgiCenter Amanda Nunkovich, Administrator 708-827-2321
Illinois Department of Health	Illinois Department of Public Health Office of Health Care Regulation Central Complaint Registry 525 W. Jefferson St., Ground Floor Springfield, IL 62761-0001
Medicare	Medicare Beneficiary Ombudsman (800) 633-4227 TTY: (877)-486-2048 https://www.cms.gov/center/special-topic/ombudsman/medicare-beneficiary-ombudsman-home
U.S. Department of Health & Human Services Office for Civil Rights	U.S. Department of Health and Human Services 200 Independence Avenue SW, Room 509F Washington, DC 20201 (800) 368-1019; TTY: (800) 537-7697 OCRMail@hhs.gov https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf
The Joint Commission	The Joint Commission Office of Quality Monitoring One Renaissance Boulevard Oakbrook Terrace, Illinois 60181 (800) 994-6610 complaint@jointcommission.org https://www.jointcommission.org/en-us/contact-us/report-a-patient-safety-event
Accreditation Association for Ambulatory Health Care	Accreditation Association for Ambulatory Health Care 3 Parkway North, Suite 201 Deerfield, IL 60015 (847) 853-6060 complaints@aaahc.org https://www.aaahc.org/ (click “Submit a Concern” or https://form.jotform.com/223076045383050)

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