Patient’s Bill of Rights and Responsibilities

Each patient receiving service shall have the following rights and responsibilities: 

1. The right to expect reasonable safety in equipment and supplies delivery and set-up.
2. The right to expect services ordered by the physician will be available and provided timely, and if referral to an alternative source is required, to be informed as soon as possible.
3. The right to participate in decisions involving care including all information concerning diagnosis in a form that can be reasonably expected to understand.
4. The right to be informed of policies and procedures including eligibility for insurance reimbursement and financial responsibility.
5. The right to be informed of names, titles and qualifications of staff delivering service.
6. The right to be informed of community resources which are best suited to patient needs.
7. The right to receive prescribed equipment and supplies in a timely manner.
8. The responsibility to comply with the physician’s prescribed treatment.
9. The responsibility to make known whether he/she understands the products and services provided.
10. The responsibility to plan for any emergencies that may occur in the home.
11. The responsibility to respect the rights, professional integrity and dignity of those providing care.
12. The responsibility to notify Surgi-Care, Inc. staff if they wish to cancel services.
13. The responsibility to notify Surgi-Care, Inc. staff if unavailable for a scheduled visit.
14. The responsibility to notify Surgi-Care, Inc. staff of any change in physician.
15. The responsibility to contact Surgi-Care, Inc when equipment is not working properly.
16. The responsibility to properly store, clean and maintain equipment and supplies as recommended by the manufacturer and Surgi-Care, Inc.
17. The right to be fully informed orally and in writing, prior to or at time of

admission, the services and/or products and equipment available directly or by contract.

1. The right to be fully informed orally and in writing, prior to or at time of admission, Surgi Care ownership and control.
2. The right to be fully informed orally and in writing, prior to or at time of admission, any specific charges for service to be paid by the client and those charges covered by insurance, third-party payment or public benefit programs.
3. The right to be fully informed orally and in writing, prior to or at time of admission, billing policies, payment procedures and any charges in the information provided on admissions as they occur within 15 days from the date Surgi Care is made aware of change.
4. The right to be fully informed orally and in writing, prior to or at time of admission, the client’s right to participate in the plan for care and/or any change in the plan before it is made.
5. The right to be fully informed orally and in writing, prior to or at time of admission, Surgi Care’s grievance procedures which includes contact names, phone numbers, hours of operation and how to communicate problems to the company.
6. The right to document a response from Surgi Care regarding investigations and resolution of the grievance.
7. The right to be advised of the availability, purpose and appropriate use of State, Medicare and CHAP hotlines.
8. The right to make informed decisions about care and treatment plans and to receiving information in a way that is understandable to the client.
9. The right to be notified in advance of treatment options, transfers, when and why care will be discontinued.
10. The right to receive and access services consistently and in a timely manner in accordance with Surgi Care’s stated operational policy.
11. The right to receive disclosure information regarding any beneficial relationships Surgi Care has that may result in profit for the referring physician.
12. The right to be referred to another provider organization if Surgi Care is unable to meet the client’s needs or if the client is not satisfied with the care they are receiving.
13. The right to voice grievances regarding treatment, care or respect for property that is or fails to be furnished by anyone providing services on behalf of Surgi Care without reprisal for doing so.
14. The right to document a response from Surgi Care regarding investigations and resolution of the grievance.
15. The right to be advised of the availability, purpose and appropriate use of State, Medicare and CHAP hotlines.
16. The right to not receive any experimental treatment without the client’s specific agreement and full understanding of information explained.
17. The right to be free from any mental abuse, physical abuse, neglect or exploitation of any kind by Surgi Care staff.
18. The right to have his/her property treated with respect and consideration.
19. The right to confidentiality of his/her clinical records and Surgi Care’s policy of accessing and disclosure of clinical records
20. The right to information regarding Surgi Care’s liability insurance upon request.

I have read and understand the above Patient’s Bill of Rights and Responsibilities. I acknowledge and understand that only my physician may deny my rights as a patient for good cause, and that my physician in my record will document the denial of such rights. I acknowledge and understand that Surgi Care has not admitted me as a patient in its service until such a time as (1) the Surgi Care patient assessment and training process has been completed, including, but not limited to, an assessment of the site of care, (2) Surgi Care has made a determination that, subject to the continued fulfillment of any admission criteria, I am eligible for admission based on its admission criteria, and (3) I have executed the Surgi Care consent form/rental agreement.

CHAP Hotline:  1-800-699-1656                     Medicare Hotline:  1-800-447-8477