YOU HAVE CERTAIN RIGHTS.

You have the right to:

1. Be treated with respect, consideration and dignity.

2. High-quality medical care delivered in a safe, timely, efficient and cost-effective manner and the right to be 

assured that the expected results can be reasonably anticipated.

3. Privacy to the extent possible.

4. Have your disclosures and records treated confidentially and, except when required by law, those disclosures 

and records will not be released without your approval.

5. Be provided, to the degree known, complete information concerning your diagnosis, evaluation, treatment and 

prognosis. 

6. Copies of your medical records at a nominal cost and, if you request it, those records will be transferred to 

another practitioner in a timely manner.

7. Be informed of all reasonable options or alternatives for care and/or treatment and of the potential advantages 

and disadvantages of each including the advantages or disadvantages and the alternatives to having the 

procedure performed in an office or other out-patient facility.

8. Participate in decisions regarding all aspects of care.

9. No procedure or treatment will be undertaken without your informed consent after the alternatives mentioned in 

#7, above have been discussed with you.

10. Refuse any diagnostic procedure or treatment and to be advised of the likely medical consequences of refusal.

11. Know all of your rights as outlined above.

12. Know the conduct expected of you in the facility and the consequences of failure to comply with these 

expectations.

13. Know the services available at the facility

14. Know the provisions for after-hours and emergency care.

15. Know if any of the planned procedures or treatments is part of a research study and the right to refuse to 

participate in that study.

16. Know whether or not your providers are insured.

17. Know how to go about expressing suggestions to the facility and the policies regarding grievance procedures 

and external appeals in the event that you are dissatisfied with your treatment.

18. Know the name of your provider.

19. You have the right to know what fees are expected and what the payment policies are.

20. You have the right to know what your provider’s credentials are.

21. You have the right to change providers.

YOU ALSO HAVE CERTAIN RESPONSIBILITIES:

You have the responsibility to:

1. Accurately and completely provide all clinical personnel with the health information they need including any 

medications you are taking.

2. Follow directions of the nurse or physician with regard to diet and/or medication.

3. Abstain from using drugs that have not been prescribed for you and that you have not revealed to the physician.

4. Abstain from the use of alcohol as directed by your nurse or physician.

5. Inform the nurse or physician if you do not understand any directions or you do not understand the course of 

treatment planned for you.

6. Timely pay all medical bills which are not in dispute and to forward to us any monies you receive from any 

insurance company for our services.