THIS NOTICE DESCRIBES YOUR PATIENT RIGHTS AND RESPONSIBILITIES BEFORE RECEIVING MEDICAL TREATMENT AND SERVICES. PLEASE REVIEW IT CAREFULLY.
Hopebridge LLC (“Hopebridge”) is committed to an environment that respects and protects your rights in accordance with applicable laws and regulations while providing quality health care services. This Notice of Patient Rights (“Notice”) describes the Patient, including their parent (s), legal guardian and authorized representative, rights and responsibilities before receiving medical treatment or before care is terminated, and is available, upon request, at all Hopebridge locations.
I. Patient Rights
Please read the following and sign that you have been informed of your rights:
- To be given informed information regarding the medical treatment and services to be provided.
- To provide consent to receive medical treatment prior to receiving services.
- To have input into the development, implementation and participation of the individualized plan of care and receipt of treatment while being informed of the plan’s content.
- To request an in-person review of the plan of care with the clinical staff.
- Confidential medical information with access in accordance with the Notice of Privacy Practices.
- To accept or refuse medical treatment and services and informed of the consequences for refusal.
- To be treated with respectful care including the consideration of psychosocial, spiritual, and cultural variables that influence the perception of illness.
- To be informed of the facility rules of conduct and to receive medical treatment and services in a safe setting free of all forms of abuse or harassment, including the use of alcohol and other drugs or infractions that may result in disciplinary action or discharge.
- Free from restraints that are not medically necessary or used as a means of coercion or discipline.
- To recommend or provide an opinion regarding the medical treatment and services received, contact the Clinic Manager or file a formal grievance refer to Section III of this Notice below.
- To file a complaint or provide an opinion in the consideration of the ethical issues that arise in the medical treatment and services provided to the Patient, please refer to Section IV of this Notice.
- To be informed of the charges and payments for services and able to request a written statement of the charges according to the Financial Policy and Agreement.
- To be informed, to refuse and provide consent regarding participation in any human experimentation or research/educational study affecting medical treatment or services.
- Request a transfer to another setting or if the needs exceed the capacity of the clinic, the clinic will assist in the transfer to another facility provided that the clinic has the resources to adequately administer the prescribed medical treatment.
- To exercise, to the extent permitted by law, the rights delineated if the Patient has been adjudicated incompetent in accordance with law, is found by clinical staff to be medically incapable of understanding the proposed plan of care or medical treatment and service, is unable to communicate preferences regarding treatment, or is a minor.
II. Patient Responsibilities
Please read the following and sign that you have been informed of your responsibilities:
- To provide, to the best of their knowledge, accurate and complete information about historical complaints, illnesses, hospitalizations, medications, and other matters relating to their health
- To report changes in the Patient’s medical condition and any extenuating circumstances that may affect the medical treatment and services provided by Hopebridge.
- To report changes in the Patient’s insurance plan or authorization for pick up.
- Understanding the contemplated course of action and what is expected.
- Following the plan of care developed and recommended by Hopebridge for their care.
- Understanding the consequences of the medical treatment, alternatives, and of not following or refusing the proposed plan of care and medical treatment or services.
- Provide two (2) weeks’ notice for planned absence or a two (2) hour notice for unplanned absence.
- Understand and agree to the financial obligations for medical treatment and services are fulfilled according to the Hopebridge Financial Policy and Agreement.
- Following the facility rules and regulations concerning Patient care and conduct.
- Being considerate and respectful of the rights and property of Patients, staff and clinic.
III. How to Complain About Medical Treatment and Services
If you feel your rights may have been violated or you disagree with the medical treatment and services received, contact our Patient Rights Representative using the toll free number at 1-855- 540-0188, email at firstname.lastname@example.org, or write a letter directly as listed below.
Attn: Kim Strunk Chief Clinical Officer
3500 Depauw Boulevard, Suite 3070
Indianapolis, IN 46268
You may also file a complaint with the Attorney General’s Office and/or Department of Human and Health Services for services and treatment received by Hopebridge in any state where Hopebridge provides services. You will not be penalized if you file a complaint.
To file a complaint with the Arizona Department of Health Services, please follow the instructions at: https://app3.azdhs.gov/PROD-AZHSComplaint-UI
IV. Changes to this Notice
We reserve the right to change this Notice and make the new Notice apply to our services as we already have as well as any services provided in the future. We will post a copy of our current Notice at our clinics. The Notice will contain the effective date on the last page with the updated dates as stated in Section V.
V. Effective Date
This Notice was effective on 1/1/2018.