Healthcare Client Rights Statement

Healthcare Client Rights Statement

Facility Name:    Date Issued:

Client Information

Insurance Information

Medical History (relevant to care)

Statement of Client Rights

As a client of this facility, you have the following rights. These rights apply regardless of the source of payment for services and may be exercised by the client or, where authorized, by the client's personal representative.

1. The right to be treated with respect, dignity and to receive care in a safe environment that preserves personal privacy.
2. The right to receive complete, current and understandable information concerning diagnosis, treatment, prognosis and available alternatives, except when contraindicated for clinical reasons; the right to participate in the development and implementation of the plan of care.
3. The right to give informed consent prior to the start of any procedure or treatment, including the right to refuse treatment and to be informed of the medical consequences of such refusal.
4. The right to confidentiality of clinical records and communications, subject to applicable law and facility policy; to access your clinical records as provided by law.
5. The right to be free from abuse, neglect and exploitation, and to be free from physical or chemical restraints used for discipline or convenience.
6. The right to receive information about facility policies regarding visitation, service charges, and eligibility for services.
7. The right to be informed of the procedure to file a grievance or complaint without fear of reprisal or denial of services.
8. The right to information about cost, payment and billing practices, including available financial assistance policies.
9. The right to prompt explanation of billings and to request an itemized bill.
10. The right to designate a personal representative to receive information and make decisions on your behalf if you are unable to do so; rights of the representative must be documented in writing.

Privacy and Notice Acknowledgment

You have the right to receive a Notice of Privacy Practices that describes how your health information may be used and disclosed and how you can obtain access to this information. You may request restrictions on certain uses and disclosures and may revoke authorization to use or disclose information at any time, except to the extent that action has already been taken in reliance on the authorization.

  I acknowledge receipt of the facility's Notice of Privacy Practices.

Consent, Refusal and Designation

You have the right to be informed about proposed care or treatment and alternatives, including the right to refuse treatment. If you refuse recommended care, the facility will inform you of the potential health consequences of that refusal and document the refusal in your clinical record.

  I understand my right to accept or refuse medical or surgical treatment.

  I designate a personal representative to act on my behalf regarding my health care decisions and access to my health information.

Grievance and Appeal Process

You may file a grievance if you believe your rights have been violated or you are dissatisfied with care. The facility shall investigate grievances promptly and respond in writing. Filing a grievance will not affect your access to services.

Access to Records and Confidentiality

You have the right to access or request amendment of your health records in accordance with applicable law. Requests will be processed within a reasonable time and reasonable fees may apply for copying or postage. The facility will require appropriate identification and may require a written request to release records to third parties.

Client Responsibilities

Clients have responsibilities that support safe, effective care. These include providing accurate and complete health information; following the agreed plan of care; respecting the rights of other clients and staff; and meeting financial obligations for services received.

Authorization and Expiration

This Client Rights Statement documents that the client has been informed of the rights and responsibilities contained herein. Unless otherwise specified, this acknowledgment remains in effect for the duration of care at this facility.

Acknowledgment and Certification

I hereby acknowledge that I have received and been given the opportunity to discuss this Healthcare Client Rights Statement. I understand the rights described above and that I may ask questions about my care, refuse treatment, and file grievances without retaliation. I certify that the information I have provided on this form is true and accurate to the best of my knowledge.

Sign Now