Healthcare Participant Rights Form

HEALTHCARE PARTICIPANT RIGHTS FORM

This form documents the rights afforded to a participant receiving health care services from the facility. It is intended to inform the participant (or authorized representative) of legal and administrative rights related to care, records, privacy, and grievance procedures. Signing below acknowledges receipt of this statement of rights but does not constitute consent to any specific treatment or relinquishment of legal protections.

Participant Information

Date of Birth:    Gender:

Phone:    Emergency Contact Name:    Emergency Contact Phone:

Insurance Information

Policy Number:    Group Number:

Medical History (Relevant)

Participant Rights (Summary and Notice)

Right to Information: You have the right to receive clear, understandable information about your diagnosis, recommended treatments, expected outcomes, and reasonable alternatives. You may request clarification and additional information about proposed care and services.

Right to Informed Consent: Except in emergencies, your informed consent must be obtained before significant procedures or treatments. You may refuse any treatment to the extent permitted by law, and your refusal will be documented in your medical record. Refusal of recommended treatment may limit available services.

Right to Privacy and Confidentiality: Your health information will be protected as required by law. Information about your care will be shared only with those involved in your treatment, billing, or as otherwise authorized by you or required by law.

Right to Access Records: You have the right to request access to your medical records, request corrections, and receive a copy of your records in a timely manner subject to applicable legal processes and applicable fees for copying.

Right to Participate in Care Planning: You have the right to participate in developing and implementing your care plan, including discharge planning and coordination of follow-up care.

Right to File a Grievance: If you believe your rights have been violated, you may file a complaint or grievance with the facility. Filing a grievance will not jeopardize your access to care. Provide details below so we may respond.

Right to Non-Discrimination and Respect: You will be treated with dignity and respect without discrimination on the basis of race, color, national origin, sex, age, disability, religion, sexual orientation, or other protected characteristic.

Right to Pain Management and Comfort Measures: You are entitled to assessment and management of pain and comfort needs to the extent consistent with safe practice and clinical judgment.

Acknowledgment and Preferences

I acknowledge that I have received or been offered a copy of the Participant Rights statement and that the rights described above have been explained to me in terms I understand.

Interpreter required:    Preferred language:

Form valid through (optional):

Legal Notice

This acknowledgement of rights is provided to inform you of protections and procedural rights applicable to your care. It does not alter statutory obligations of the facility nor does it waive any rights afforded to you by applicable law. If you are a legal representative signing on behalf of the participant, you affirm that you are authorized under applicable law to act on the participant's behalf and agree to provide documentation of that authority if requested.

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