PATIENT RIGHTS and RESPONSIBILITIES
Pinnacle Surgery Center is committed to ensuring the following Patient Rights:
The right to have a state appointed representative act on your behalf that may exercise any and all rights afforded to you if you have been determined to be incompetent under a state legal process and are not capable of exercising your rights independently.
- The right to make informed decisions regarding your care and to delegate your right to make informed decisions to a representative or surrogate of your choice. To the degree permitted by state law, and to the maximum extent practicable, the Center must respect your wishes and follow that process.
- The right to safe, confidential and considerate care with respect, consideration and dignity.
- The right to privacy concerning your personal care.
- The right to expect all disclosures and records pertaining to your care will be treated as confidential unless reporting is permitted or required by law.
- The right to confidentiality regarding your medical care and treatment.
- The right to complete information concerning your diagnosis, evaluation, treatment and prognosis, as well as the risks and dangers of that treatment, expected outcome, and opportunity to participate in informed decisions related to your treatment. When medically inadvisable to give such information to a patient, the information is provided to a person designated by the patient (their representative or surrogate) or to a legally authorized person. The patient, patient’s representative, or surrogate also has the right to know the name of the person(s) who will implement the procedures and/or treatment and are informed of their right to change their provider if other qualified providers are available.
- The right to refuse part or all of the treatment suggested to you at the Center, including participation in human experimental research affecting your care or treatment.
- The right to treatment without regard to race, color, religion, gender, sexual preference, disability, national origin, age, veteran’s status or source of payment, except for fiscal capability thereof in accordance with Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and regulations of the U.S. Department of Health and Human Services issued pursuant to these statutes at Title 45 Code of Federal Regulations Parts 80, 84, and 91.
- The right to expect reasonable continuity of care, to know what to expect concerning your procedure(s) and expected appointment time. To be informed by your physician, or a delegate of the physician, of your continuing health care requirements following discharge.
- The right to be provided with appropriate information regarding the absence of malpractice insurance coverage.
- The right to know the facility charges which you incur for treatment, payment policies, immediate and long-term financial implications, regardless of the source of payment.
- The right to expect that within its capacity, the ambulatory surgery center must provide evaluation, service and/or referral as indicated by the urgency of the case. When medically necessary, a patient may be transferred to another facility.
- The right to express any suggestion, complaints, and grievance, either verbally or in writing, regarding your care without discrimination or reprisal and be free from all forms of abuse or harassment.
- The right to accurate and true marketing and/or advertising regarding the competence and capabilities of the organization.
- The right to submit an Advance Directive.
- The right to access the Colorado Advance Directives Consortium. Upon request, a patient, patient’s representative or surrogate, will be provided with this law and/or the Colorado Advance Directive Form.
- The right to access the Advanced Health Care Directive in Caring Connections, a program of the National Hospice and Palliative Care Organization (NHPCO), who administers a national consumer engagement initiative to improve care at the end of life. This program includes instructions for completing the Colorado Advance Directive for Healthcare, learning options for end-of-life services and care, implementing plans to ensure your wishes are honored, voicing your decisions to family, friends and healthcare providers, engaging in personal or community efforts to improve end-of-life care, and the Colorado Durable Power of Attorney for Healthcare.
- The right to be informed, if you are a Medicare beneficiary, the role of the Medicare Beneficiary Ombudsman. The Ombudsman ensures that Medicare beneficiaries receive the information and help that they need to understand their Medicare options and to apply their Medicare rights and protections.
As a patient, you are responsible for:
- Providing accurate and complete information concerning your present health condition(s), past medical history, and other matters relating to your health.
- Informing your provider about any living will, medical power of attorney, or other directive that could affect your care.
- Asking questions when you do not understand information or instructions or do not believe you can follow through with the treatment prescribed by your physician.
- Being considerate of the rights of other patients and the staff of the Center by assisting in the control of noise, not smoking, and limiting the number of visitors.
- Assuring your financial obligation is fulfilled as promptly as possible.
- Following the treatment plan prescribed by his/her provider.
- Your actions should you refuse treatment or not follow your physician’s orders.
- Your actions in following the rules and regulations affecting patient care and conduct.
- Providing a responsible driver for transportation home and for them to remain with you for 24 hours if required by your physician provider.
The Center has the right to refuse care to or dismiss a patient from care in the event they are disruptive, uncooperative, and belligerent or physically threatening to the staff or other patients. Additionally, the Center has the right to refuse care to or dismiss a patient from care in the event the designated responsible driver is incapacitated, disruptive, uncooperative, belligerent, or physically threatening to the staff or other patients.
If you have questions concerning this policy, or in the event of a desire to file a complaint, please contact:
- Clinical Director-Section 504 Coordinator, Pinnacle Surgery Center, 2770 N. Union Blvd., Suite 180, Colorado Springs, CO 80909, Phone: 719-418-4700.
- Colorado Department of Public Health is the responsible agency for ambulatory surgical centers’ complaint investigation. Complaints may be registered with the department by phone (800) 886-7689, by fax (303) 753-6214, in writing to CDPHE, HFEMSD-A2, Attention: Ambulatory Surgery Center Complaint Intake, 4300 Cherry Creek Drive South, Denver, CO 80246-1530, or email firstname.lastname@example.org. A complainant may provide his/her name, address and phone number to the Department. Anonymous complaints may be registered. All complaints are confidential.
- Office of the Medicare Ombudsman, http://www.medicare.gov/ombudsman/resources.asp.
- Caring Connections website, http://www.caringinfo.org/files/public/ad/Colorado.pdf.
- Colorado Advance Directives Consortium, http://www.coloradoadvancedirectives.com/.
PATIENT NOTIFICATION AND ACKNOWLEDGEMENT
Notice of Rights and Responsibilities
Pinnacle Surgery Center has established a Patient’s Bill of Rights and Responsibilities, which is provided verbally and in writing in a language and manner the patient, patient’s representative or surrogate understands prior to their procedure. Pinnacle Surgery Center expects that observance of these rights will contribute to more effective patient care and greater satisfaction for patients, physicians and the Center.
Notice of Privacy Practices PHI and HIPPA
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA) I have rights to privacy regarding my protected health information. I understand that this information can and will be used to:
- Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
- Obtain payment from third-party payers.
- Conduct normal healthcare operation such as quality assessment and physician certification.
A complete copy of Pinnacle Surgery Center’s notice of privacy practice is posted in the Center. I have been informed by this Center of their written Notice of Privacy Practices containing a more complete description of the uses and disclosures of my healthy information. I have been given the right to review such Notice of Privacy Practices from time to time and that I may contact them to obtain a current copy. I understand that I may request in writing that the Center restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I understand that I may revise this consent in writing at any time, except to the extent that the Center has already taken action relying on this consent.
I Give Permission for my protected healthy information (PHI) to be disclosed for purposes of communicating results, findings and care decisions to the family members and others.
No. Limited disclosure to persons listed below:
Name: __________________________________________________ Date: _____________________
Name: __________________________________________________ Date: _____________________
Financial Disclosure/Ownership in the Center
Pinnacle Surgery Center is privately owned and has informed the patient prior to the procedure that their physician may have a proprietary interest in this facility. I have the right to choose the facility of my choice for health related services. I have been given this option and choose to have my procedure at Pinnacle Surgery Center.
It is the policy of Pinnacle Surgery Center, regardless of any advance directive or instructions from a health care surrogate or power of attorney, that an unexpected medical emergency, which occurs during treatment at this facility, will be aggressively managed with resuscitative or other stabilizing measures followed by emergency transfer to the closest hospital. The receiving hospital will implement further treatment or withdrawal of treatment measures already begun in accordance with patient wishes, advance directive or health care directive or health care power of attorney.
Please check the appropriate box
Yes, I have an advance health care directive, living will and/or a power of attorney.I have provided a copy of my advance health care directive, living will and/or power of attorney to the Center.
No, I do not have an advance health care directive, living will and/or a power of attorney.
Yes, I would like additional information on advance health care directives including information on my states law regarding advance health care directives.
All alleged grievances will be fully documented, investigated and reported to the Administrator of Pinnacle Surgery Center. Any substantiated allegation will be reported to the State of Colorado and/or Local authority. The grievance documentation will be included in the process of how the grievance was addressed and the patient will be provided a written notice of the decision within fifteen (15) days of receipt of the grievance.
By signing this document, I acknowledge that the above information was given to me prior to my procedure, and that I have read and understand the information. I agree to the policies of Pinnacle Surgery Center. If I have indicated I would like additional information, I acknowledge receipt of that information.
Patient Signature (If patient is unable to sign, please indicate relationship / Witness Signature Date