Healthcare Combined Bill of Rights

Healthcare Combined Bill of Rights

Facility Name:    Effective Date:

Patient Information

Insurance Information

Medical History (Relevant)

Statement of Patient Rights

The patient has the right to receive care in a safe, respectful, and nondiscriminatory manner. The following rights are afforded to every patient receiving services from this facility. Please review each item and acknowledge understanding by checking the corresponding box.

I have the right to privacy and confidentiality of my medical records and personal health information except as required by law. I understand how my information may be used for treatment, payment, and healthcare operations.

I have the right to receive information about my diagnosis, treatment options, expected benefits, material risks, and potential complications in terms I can understand, and to participate in decisions about my care.

I have the right to refuse treatment to the extent permitted by law and to be informed of the medical consequences of refusal. Refusal will be documented in my medical record.

I have the right to access and obtain a copy of my medical records within the time frame set by applicable law, subject to any permitted limitations or reasonable copying fees.

I have the right to be informed in advance of any transfer or discharge and to receive an explanation of my continuing healthcare needs, prognosis, and alternatives.

I have the right to voice complaints about the care I receive without fear of reprisal and to have complaints investigated and responded to in accordance with facility policy.

I have the right to have my pain assessed and treated as part of my care plan and to be informed about pain management options.

I have the right to receive language assistance, including interpretation and translation services, and culturally respectful care.

Patient Responsibilities

Patients have the responsibility to provide accurate and complete health information, to follow prescribed treatment plans, to ask questions and seek clarification when needed, and to fulfill financial obligations for services received. Patients must respect the rights of other patients and facility staff.

I acknowledge financial responsibility for charges not covered by insurance and agree to cooperate with billing and payment procedures.

Privacy and Release of Information

By signing this form the patient acknowledges receipt of the facility's privacy practices and authorizes the use and disclosure of protected health information for purposes of treatment, payment, and healthcare operations as necessary for care. The patient may request restrictions on certain disclosures; such requests will be considered in accordance with applicable law.

Authorization to release additional records: I authorize release of my health information to third parties as needed for care coordination and payment.

Complaint, Appeals and Advocacy

If the patient believes rights have been violated, the patient may submit a complaint or appeal to facility management. Complaints should include the date, description of the concern, and requested resolution. The facility will document and investigate complaints and provide a written response in accordance with internal procedures and applicable law.

Advance Directives and Decision-Making

Patients have the right to make advance directives and appoint a healthcare proxy. The facility will document advance directives in the medical record and respect legally recognized directives to the extent permitted by law.

I have been informed of my rights to create or update advance directives and to designate a decision-maker for medical care.

Acknowledgment and Certification

By signing below, I acknowledge that I have received, read, or been offered an explanation of this Healthcare Combined Bill of Rights. I certify that the information provided on this form is true and accurate to the best of my knowledge. I understand that I may request a copy of this acknowledgement for my records.

If this form is signed by a legal guardian, parent of a minor, or other authorized representative, the representative certifies that they are authorized to sign on behalf of the patient and will attach documentation verifying such authority if requested by the facility.

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