Healthcare Client Rights Disclosure

HEALTHCARE CLIENT RIGHTS DISCLOSURE

Patient Information

Client Name:

Date of Birth:    Gender: Male Female Other Prefer not to say

Insurance Information

Medical History (brief)

Client Rights — Disclosure and Acknowledgement

The following statements describe rights afforded to clients receiving care from this facility. These rights are guaranteed to the extent permitted by applicable law. They include, but are not limited to, the following:

1. The right to be treated with respect, dignity and consideration of personal privacy; the right to receive care without discrimination; and the right to a safe environment.

2. The right to receive accurate, timely and understandable information about diagnosis, treatment, alternatives, risks and expected outcomes in terms that the client can reasonably understand. The client has the right to participate in decisions about care, including the right to refuse treatment to the extent permitted by law.

3. The right to access the client’s medical records and to request amendment of incorrect information, consistent with organizational policies and applicable law.

4. The right to confidentiality of personal and medical information, except as authorized by the client or as required by law. Release of information to third parties requires written authorization from the client, except where disclosure is permitted without authorization.

5. The right to be informed of financial obligations and the billing and payment policies applicable to services rendered.

6. The right to receive information about the facility’s grievance and complaint process, and to file a complaint or grievance without fear of retaliation. Complaints may be made verbally or in writing and will be addressed in a timely and impartial manner.

7. The right to interpreter services and accommodations for sensory or communication needs. If an interpreter or special assistance is required, the client may request such services.

HIPAA / Privacy Notice Acknowledgement

I acknowledge that I have been offered a copy of the facility’s Notice of Privacy Practices describing how protected health information may be used and disclosed, and how I can access this information. I understand my rights regarding PHI and that further authorizations are required for disclosures beyond treatment, payment and healthcare operations.

I understand that I may authorize or revoke release of my health information in writing at any time, subject to legal and contractual restrictions and to the extent the facility has not already acted in reliance on the authorization.

I acknowledge that I received and understand the Client Rights Disclosure.

I acknowledge that I was offered the Notice of Privacy Practices.

Permission to leave health information by voicemail or message at the phone number provided.

I request interpreter or communication assistance for the following language / modality:

Grievance and Complaint Procedure

Clients have the right to file grievances about any aspect of care or billing. Complaints will be investigated and resolved in a timely manner; the client will be informed of the outcome. Filing a grievance will not affect access to care or treatment.

By checking the box below, I confirm I understand the grievance procedure and have been informed how to submit a complaint.

I understand the grievance and complaint process.

Authorizations & Expiration

Certain disclosures of protected health information will require a separate written authorization from the client. Any authorization provided is valid only for the time period specified below or until revoked in writing, subject to legal limitations.

Certification

By signing below, I certify that I am the client named above or the client’s authorized representative. I have read (or had read to me) this Client Rights Disclosure, I understand my rights as described, and I have had the opportunity to ask questions. My signature indicates consent to receive care consistent with these rights and acknowledgment of the policies described herein.

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